ome  Series 


DISEASES 


OF  THE                                         i 

EYE  AND  EAR          i 

ALLING                   1 

GRIFFIN 

;5 

PEDERSEN 


^    JOHN  K.  MORRIS,  M.  IX 

^be  (IDebical  Epitome  Series, 
DISEASES  OF  THE  EYE  AND  EAR. 

A  MANUAL  FOR  STUDENTS  AND  PRACTITIONERS, 

BY 

ARTHUR  N.  ALLING,  M.D., 

Clinical  Professor  of  Ophthalviology  in  the  Yale  University,  Depanment 
of  Medicine,  New  Haven,  Connecticut, 

AND 

OVIDUS  ARTHUR  GRIFFIN,  B.S.,  M.D., 

lAite  Demonstrator  of  Ophthalmology  and  Otology,  University  of  Michigan,  and 
Oculist  and  Aurist,  University  Hospital,  Ann  Arbor,  Michigan. 

SERIES    EDITED   BY 

VICTOR  COX  PEDERSEN,  A.  M.,  M.  D., 

Instructor  in  Surgery  and  Anesthetist  and  InstruMor  in  Anestliesia  at  the  New  York  Poly- 
clinic Medical  School  and  Hospital ;  Genito-  Urinary  Surgeon  to  the  Out-Paiient 
Departments  of  the  New  York  and  the  Hudson  Street  Hospitals  ; 
Anesthetist  to  the  Roosevelt  Hospital. 


I  LEA  BROTHERS  &  CO., 

PHILADELPHIA    AND    NEW    YORK. 


Entered  according  to  Act  of  Congress,  in  the  year  1905,  by 

LEA  BROTHERS  &  CO., 

In  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


Klectbotyped  by  press  of 

WESTCOTT  &  THOMSON,   PHILAOA.  WM.  J.   DORNAN,   PHILADA. 


Ass 


r 

AUTHORS'  PREFACE,  t:  i^  ^ ,  ^^ 


In  the  following  pages,  the  authors  have  endeavored  to 
present  the  subjects  of  Ophthalmology  and  Otology  in  as 
clear,  thorough,  and  interesting  a  manner  as  the  limited  space 
would  permit.  Of  necessity  and  intentionally,  only  the 
cardinal  facts  have  been  mentioned,  since  their  experience 
as  teachers  has  impressed  the  writers  with  the  fact  that  a 
complex  consideration  is  confusing  to  the  beginner,  but  that 
after  the  fundamental  principles  have  been  mastered,  the  de- 
tails of  a  more  extensive  work  are  readily  acquired.  While 
the  matter  has  been  prepared  primarily  for  the  use  of  the 
student,  it  is  believed  that  it  will  prove  of  equal  service  to 
the  practising  physician  in  the  management  of  his  cases.  To 
render  the  text  more  effective,  numerous  illustrations  have 
been  employed,  which  should  be  carefully  studied  in  con- 
nection therewith.  That  the  work  might  present  a  general 
resume,  the  authors  have  consulted  the  principal  authorities, 
to  whom  they  acknowledge  their  indebtedness  for  many  of 
the  views  contained  herein. 

New  Haven,  1905.  A.  N.  A. 

Ann  Arbor,  1905.  O.  A.  G. 

i       285 


EDITOR'S  PREFACE. 


In  arranging  for  the  editorship  of  The  3Iedical  Epitome 
Series  the  publishers  established  a  few  simple  conditions, 
namely,  that  the  Series  as  a  whole  should  embrace  the  entire 
realm  of  medicine ;  that  the  individual  volumes  should  au- 
thoritativ-ely  cover  their  respective  subjects  in  all  essentials ; 
and  that  the  maximum  amount  of  information,  in  letter- 
press and  engravings,  should  be  given  for  a  minimum  price. 
It  was  the  belief  of  publishers  and  editor  alike  that  brief 
works  of  high  character  would  render  valuable  service  not 
only  to  students,  but  also  to  practitioners  who  might  wish 
to  refresh  or  supplement  their  knowledge  to  date. 

To  the  authors  the  editor  extends  his  heartiest  thanks  for 
their  excellent  work.  They  have  fully  justified  his  choice 
in  inviting  them  to  undertake  a  kind  of  literary  task  which 
is  always  difficult — namely,  the  combination  of  brevity,  clear- 
ness, and  comprehensiveness.  They  have  shown  a  consistent 
interest  in  the  work  and  an  earnest  endeavor  to  cooperate 
with  the  editor  throughout  the  undertaking.  Joint  effort  of 
this  sort  ought  to  yield  useful  books,  brief  manuals  as  con- 
tradistinguished from  mere  compends, 

5 


6  EDITOR'S  PREFACE. 

In  order  to  render  the  volumes  suitable  for  quizzing,  and 
yet  preserve  the  continuity  of  the  text  unbroken  by  the 
interpolation  of  questions  throughout  the  subject-matter, 
which  has  heretofore  been  the  design  in  books  of  this  type, 
all  questions  have  been  placed  at  the  end  of  each  chapter. 
This  new  arrangement,  it  is  hoped,  will  be  convenient  alike 
to  students  and  practitioners. 

V.  c.  p. 

New  York,  1905. 


V 


^  JOHN  K.  MORRIS,  M.  ft 
CONTENTS. 

THE   EYE   AND   ITS   DISEASES. 

CHAPTEK  I. 

PAGES 

Examination  of  the  Eye  and  its  Appendages    ....   =   .   17-31 

^           CHAPTER  II. 
Diseases  of  the  Lacrymal  Apparatus .   .   .  31-36 

^ 

CHAPTER  III. 
Diseases  of  the  Lids =   ..-,,.  37-48 

CHAPTER  IV. 
Diseases  of  the  Conjunctiva .   ,   .  .   ,   »   .  49-64 

CHAPTER  V. 

Diseases  of  the  Cornea »   .   »   .   .   ,    64-75 

CHAPTER  VL 

Diseases  of  the  Sclera 76-78 

CHAPTER  VII. 

Diseases  of  the  Iris 78-84 

7 


8  COjSTENTS. 

CHAPTEK  VIII. 

PAGES 

Diseases  of  the  Pupil .    .    ,       84-86 

CHAPTEK  IX. 

Diseases  of  the  Ciliary  Body ,   .       86-88 

CHAPTER  X. 
Diseases  of  the  Lens ....,,       88-99 

CHAPTER  XL 

Diseases  of  the  Vitreous 99-100 

CHAPTER  XXL 
Diseases  of  the  Retina ....,,..   101-108 

CHAPTER  XIII. 
Diseases  of  the  Choroid 109-111 

CHAPTER  XIV. 
Diseases  of  the  Optic  Nerve 112-115 

CHAPTER  XV. 

Diseases  of  the  Orbit <       o   .       .  116 

CHAPTER  XVI. 

Diseases  of  the  Eyeball 117-119 

CHAPTER  XVIL 
Glaucoma 120-124 

CHAPTER  XVIIL 
Sympathetic  Ophthalmia .   125-127 


CONTENTS. 
CHAPTER  XIX. 


PAGES 


I  Refraction = 127-135 

CHAPTER  XX. 
The  Muscles  of  the  Eye 135-142 


THE   EAE   AND   ITS   DISEASES. 

CHAPTER  I. 
Anatomy  and  Physiology 143-162 

CHAPTER  11. 

Examination  of  the  Patient 162-178 

I  CHAPTER  HI. 

Diseases  of  the  Auricle  and  External  Auditory  Meatus  178-196 

CHAPTER  IV. 
Diseases  of  the  Middle  Ear 196-242 

CHAPTER  V. 
Diseases  of  the  Internal  Ear 242-246 


^    JOHN  K.  MORRIS,  M.  D. 

THE  EYE  AND  ITS  DISEASES. 


CHAPTER  I. 
EXAMINATION  OF   THE  EYE  AND  ITS  APPENDAGES. 

Lachrymal  Apparatus. — Under  favorable  conditions  the 
edge  of  the  lachrymal  gland  may  be  felt  as  it  lies  in  its  fossa  on 
the  upper  outer  wall  of  the  orbit,  back  of  the  orbital  ridge. 
Enlargement,  tumor,  or  prolapse  should  be  made  out.  The  pres- 
ence of  excess  of  tears  in  the  conjunctival  sac  (epiphora,  stilli- 
cidium)  is  indicated  by  a  watery  line  along  the  edge  of  the 
lower  lid  and  at  the  inner  canthus.  Attention  should  be 
turned  to  the  conducting  apparatus,  and  the  small  openings 
(puncta)  on  the  margin  of  each  lid  near  the  inner  canthus 
should  be  found  open  and  lying  against  the  eyeball.  The 
region  overlying  the  lachrymal  sac  is  next  examined  for  red- 
ness and  swelling.  The  finger,  with  the  ball  turned  toward 
the  nose,  is  pressed  firmly  over  the  lachrymal  sac,  and  at  the 
same  time  the  puncta  are  watched  to  observe  the  escape  of 
discharge,  which  would  indicate  that  the  lachrymal  (nasal)  duct 
is  closed.  By  introducing  the  point  of  a  lachrymal  syringe  into 
the  lower  punctum,  solutions  may  be  forced  into  the  lachrymal 
sac  and  out  again  through  the  upper  punctum,  if  it  seems 
desirable  to  determine  the  patency  of  these  channels.  The 
character  of  the  fluid  may  also  be  observed  with  reference  to 
the  presence  of  abnormal  secretion  in  the  lachrymal  sac. 

Lids. — The  width  and  length  of  the  opening  between  the 
upper  and  lower  lids  (palpebral  fissure)  should  be  observed, 
as  well  as  any  drooping  of  the  upper  lid  (ptosis). 

The  thin  skin  covering  the  eyelids  should  then  be  examined 
2— E.  E.  17 


18  EXA3IINATI0N  OF  THE  EYE  AND  ITS  APPENDAGES. 

for  any  disease  which  may  occur  there,  and  for  oedema,  swell- 
ing, or  redness. 

The  margins  of  the  lids  should  receive  a  thorough  inspec- 
tion. Note  the  number  and  character  of  the  cilia,  as  well  as 
their  direction,  being  sure  that  no  fine  lashes  are  turned  in 
against  the  eyeball  (trichiasis),  and  that  there  is"  not  a  double 
row  of  lashes  (distichiasis).  Note  the  presence  of  redness, 
swelling,  discharge,  scales,  crusts,  watery  cysts,  ulcers,  tumors, 
pediculi,  or  ova.  If  the  upper  or  lower  lid  is  found  rolled 
inward,  so  that  the  margin  is  turned  against  the  eyeball,  the 
condition  is  called  entropion.  When  the  margin  is  turned 
outward,  showing  more  or  less  of  the  conjunctiva,  it  is  known 
as  ectropion. 

One  should  next  investigate  the  inner  surface  of  the  upper 
lid  by  turning.     This   is   accomplished   by  seizing  the  eye- 

FlG.  1. 


Desmarres'  lid-retractor. 


lashes  with  a  firm  hold  between  the  thumb  and  finger  of  the 
left  hand,  with  the  thumb  below.  The  patient  must  then 
look  down,  and  any  smooth  instrument,  preferably  about  the 
size  of  a  match,  should  be  pressed  into  the  skin  just  under  the 
edge  of  the  orbital  ridge.  If  this  instrument  is  pressed  down, 
folding  the  skin  before  it,  while  the  eyelashes  are  pulled  up 
outside  the  folded  skin,  the  lid  will  turn,  and  may  be  held  in 
place  for  inspection  by  the  thumb,  which  is  conveniently 
present.  The  inner  surface  of  the  lid  should  be  examined 
as  to  the  condition  of  the  conjunctiva,  congestion,  thickening, 
granulations,  or  points  of  discoloration. 

The  inner  surface  of  the  lower  lid  may  be  examined  by 
placing  the  finger  well  up  to  the  edge  and  pulling  down  while 
the  patient  looks  up. 

To  make  satisfactory  examination  of  the  lids  and  eyeball 


CONJUNCTI VA- SCLERA .  19 

in  young  children  the  head  must  be  held  face  up  between  the 
surgeon's  knees  and  the  lids  pried  apart  by  the  fingers  or  by 
the  use  of  lid-retractors.     (See  Fig.  1.) 

Conjunctiva. — The  method  of  examining  the  palpebral  con- 
junctiva has  just  been  described.  Tlie  transition  of  the  pal- 
pebral into  the  ocular  conjunctiva  (retrotarsal  fold,  fornix,  cul- 
de-sac)  should  not  be  overlooked.  AYhen  the  upper  lid  has 
been  turned,  the  edge  of  the  tarsal  cartilage  must  then  be 
raised  by  a  blunt  instrument. 

The  ocular  (bulbar)  conjunctiva  is  easily  accessible,  and  con- 
gestion, thickening,  oedema  (chemosis),  and  tumors  noted.  By 
using  pressure  with  the  edge  of  the  lid  it  will  be  seen  that  the 
conjunctiva  is  loosely  attached  to  the  eyeball,  except  about 
the  cornea,  where  it  is  adherent  by  a  narrow  zone  (limbus). 
Presence  of  lesions  in  this  locality  should  be  noted. 

Conjunctival  Discharge. — The  student  must  learn  to  distin- 
guish the  various  forms  of  discharge  found  in  the  conjunc- 
tival sac : 

a.  Watery  (tears,  epiphora). — Found  in  stenosis  of  con- 
ducting apparatus,  etc. 

b.  Mucous. — Mucilaginous,  but  clear.  Example,  chronic 
conjunctivitis. 

c.  llucopnrident. — Tenacious,  white  or  yellow — as  in  acute 
and  chronic  conjunctivitis. 

d.  Purulent. — Creamy.  Runs  out  of  the  eye  when  the  lids 
are  separated — as  in  gonorrhoeal  ophthalmia. 

Congestion  of  the  Eyeball. — a.  Coiijimctival. — This  form 
may  be  easily  distinguished  by  the  fact  that  the  vessels  are 
movable  with  the  conjunctiva  over  the  eyeball.  Found  in 
conjunctivitis. 

b.  OHiaiy  or  Oircumcorneal. — A  fine  vessel  congestion  most 
intense  about  the  periphery  of  the  cornea.  Pink  or  viola- 
ceous in  color.  Due  to  irritation  or  inflammation  in  cornea, 
iris,  or  ciliary  body. 

c.  Scleral — Conjunctiva  movable  over  it.  May  be  local- 
ized fine-vessel  congestion  or  general  in  form  of  large  vessels 
which  perforate  the  sclera.     In  scleritis  or  glaucoma. 

Sclera. — The  sclera  may  show  congestion,  localized  swell- 


20   EXAMINATION  OF  THE  EYE  AND  ITS  APPENDAGES. 

ings,  bulging  (staphyloma),  or  areas  of  discoloration  due  to 
scleritis  or  congenital. 

Oblique  Illumination. — Although  the  further  examination 
is  partly  carried  on  by  daylight,  the  method  of  oblique  illumi- 
nation in  a  dark  room  next  comes  into  use.  A  double  convex 
lens  of  about  2.5  inch  focus  is  held  so  that  the  image  of  the 
artificial  light  (an  Argand  burner  is  best),  which  should  be  at 
least  2  feet  away,  is  "  played ''  upon  the  eye.  The  impor- 
tance of  this  manoeuvre  is  very  great.  Another  lens  may  be 
used  to  magnify  the  illuminated  field.  Special  instruments 
have  been  devised  for  this  purpose,  called  corneal  microscopes. 

Cornea. — The  anterior  surface  of  the  cornea  should  be 
carefully  examined  by  oblique  illumination  for  irregularities, 
bloodvessels,  foreign  bodies,  ulcers,  blisters,  depressions,  and 
opacities.  One  may  observe  the  reflection  of  a  window  when 
the  patient  is  facing  it,  and  note  distortions  in  its  outline  by 
moving  the  eye. 

The  deeper  layers  of  the  cornea  should  be  examined  for 
opacities.  A  dense  white  opacity  (leucoma),  whether  super- 
ficial or  deep,  or  a  moderately  thick  cloud  (macula),  may  be 
easily  discerned  by  daylight,  but  a  faint  opacity  (nebula)  is 
best  seen  by  oblique  illumination.  The  posterior  surface  should 
be  scrutinized  for  opacities,  usually  punctate. 

Sensibility  of  the  cornea  may  be  tested  by  brushing  the  sur- 
face with  a  wisp  of  cotton.  Normally  this  is  resented  by  a 
quick  reflex. 

Anterior  Chamber. — The  depth  of  the  anterior  chamber 
should  be  noted — i.  6.,  the  distance  between  the  posterior 
surface  of  the  cornea  and  the  anterior  surface  of  the  iris  and 
lens.  The  clearness  of  the  aqueous  humor  should  be  noted  as 
well  as  the  presence  of  pus  and  exudate  (hypopyon)  or  blood 
(hyphaema). 

Iris. — The  anterior  surface  of  the  iris  should  be  observed 
carefully  and  compared  with  the  other  eye.  The  muddy  dis- 
coloration from  congestion  which  is  accompanied  by  loss  of 
detail  in  the  fine  markings  of  this  surface,  as  well  as  masses 
of  exudate,  tumors,  or  pigment-spots,  will  be  recognized  with 
a  little  experience.     Quivering  of  the  iris  when  the  eye  is 


PUPIL— ORBIT.  21 

moved  (iridodonesis  or  tremulous  iris)  is  sometimes  seen 
wlien  the  lens  is  absent  or  dislocated. 

Pupil. — The  pupil  should  be  circular  and  nearly  in  the 
centre  of  the  iris.  Great  variation  in  size  is  possible  under 
normal  conditions.  It  is  sometimes  desirable  to  record  its 
size,  which  may  be  done  by  comparing  with  an  instrument 
which  has  numerous  circular  apertures  of  measured  diameter 
(pupillometer).  The  reaction  of  the  pupil  to  light  may  be 
roughly  tested  by  alternately  covering  and  uncovering  the 
eyes  with  the  hands  before  a  window.  A  better  way  is  to 
throw  the  light  by  oblique  illumination  in  and  out  of  the 
pupil  in  the  dark  room.  The  pupil  into  which  the  light  is 
thrown  should  contract  (direct  action),  but  tlie  otiier  should 
do  so  as  well  (consensual  action).  When  the  patient  looks 
from  a  distant  to  a  near  object,  the  pupil  should  also  contract 
(reaction  to  accommodation  and  convergence). 

Lens. — Tlie  lens  may  be  examined  partially  by  daylight, 
or  better  by  oblique  illumination,  as  far  as  the  size  of  the 
pupil  will  admit.  The  more  complete  examination  as  carried 
on  with  the  ophthalmoscope  will  be  described  later.  Its 
fixity  of  position  should  be  determined.  Dislocation  (luxa- 
tion) is  evidenced  by  iridodonesis  or  by  obtaining  a  view  of 
its  edi>;e,  which  is  never  seen  under  normal  conditions. 
Opacities  (cataract)  on  the  anterior  or  posterior  surface  (polar 
or  (capsular)  or  in  the  lens-substance  are  noted.  A  moderate 
amount  of  haze  in  advanced  life,  often  quite  brownish  (sclero- 
sis), is  normally  present  and  compatible  with  useful  vision. 

Vitreous  Humor. — That  part  of  the  vitreous  chamber 
which  lies  just  back  of  the  lens  is  accessible  by  daylight  and 
oblique  illumination,  and  should  be  perfectly  clear.  When 
filled  with  exudate,  involved  by  a  new  growth  or  retinal 
detachment,  these  may  be  made  out.  The  deeper  parts  of 
the  vitreous  are  examined  with  the  ophthalmoscope. 

Orbit. — The  finger  should  be  passed  about  the  bony  edge 
of  the  orbit  and  pushed  well  back  inside  about  the  eyeball  for 
the  detection  of  tumors  and  irregularities.  If  orbital  disease 
is  suspected,  the  nose  and  accessory  sinuses  should  be  inves- 
tigated. 


22  EXAMINATION  OF  THE  EYE  AND  ITS  APPENDAGES, 

Eyeball. — Note  the  position  of  the  eyeball  as  to  undue 
prominence  (exophthalmos,  proptosis)  or  recession  into  the 
orbit  (enophthalmos),  and  as  to  whether  it  is  pushed  to  one 
or  the  other  side.  Also  whether  the  eyeball  is  larger  (megal- 
ophthalmos)  or  smaller  (microphthalmos)  than  the  normal  size. 

Fig.  2. 


Loring's  ophthalmoscope. 

Ophthalmoscope. — Ophthalmoscopy  is  a  difficult  art,  and 
the  beginner  is  advised  to  embrace  every  opportunity  to 
perfect  himself.  The  principle  underlying  the  use  of  the 
ophthalmoscope  should  be  thoroughly  mastered.  The  reasons 
why  the  pupil  appears  dark  and  no  view  of  tlie  background 
(fundus)  may  be  obtained  under  ordinary  circumstances  ar^ 


OPHTHALMOSCOPE.  23 

two  :  first,  because  light  which  enters  the  eye  is  reflected  back 
to  its  source ;  and  secondly,  because  there  is  little  internal 
reflection  on  account  of  the  pigmented  background.  The 
])roblera  of  getting  in  the  path  of  the  light  returning  from 
the  interior  of  the  eye  might  be  simply  solved  by  holding  a 
hollow  tube  in  a  candle-flame.  Through  this  the  pupil  will 
appear  luminous.  Or,  if  a  hole  is  made  in  the  centre  of  a 
mirror  and  the  light  reflected  into  the  pupil,  the  observer's 
eye,  placed  at  this  aperture,  will  see  the  fundus  illuminated 
in  the  same  way.     This  is  essentially  an  ophthalmoscope. 

The  modern  complete  or  refracting  ophthalmoscope  con- 
sists of  a  revolving  disk,  near  the  circumference  of  which  is 
arranged  a  series  of  apertures  filled  with  lenses  of  various 
strengths.  These  are  made  to  pass  back  of  the  aperture  in  a 
concave  mirror.  Suitable  support  for  the  disk  and  mirror 
with  handle  make  up  the  instrument. 

There  are  four  methods  of  ophthalmoscopy  for  diagnosis  of 
lesions : 

I.  A  strong  lens  in  the  disk,  say  +16  D.,  is  turned  behind 
the  aperture.  An  Argand  burner  is  placed  on  a  level  with 
the  patient's  eye,  on  the  same  side  of  the  head,  so  that  the 
shadow  of  the  temple  falls  on  the  tip  of  the  nose.  The  ob- 
server approaches  the  patient  on  the  same  side  as  the  light, 
while  reflecting  it  into  the  eye  and  looking  through  the  aper- 
ture with  the  same  eye  as  that  observed.  By  this  method  the 
cornea,  lens,  and  anterior  part  of  the  vitreous  may  be  studied 
in  great  detail  with  magnified  image. 

II.  With  no  lens  behind  the  aperture,  at  a  distance  of  about 
12  inches,  the  light  is  reflected  into  the  eye.  The  pupil 
appears  luminous,  but  the  details  of  the  fundus  can  not  be 
seen.  If  there  are  opacities  in  the  cornea,  lens,  or  vitreous, 
they  will  appear  as  black  spots  in  the  brilliant  pupil. 

The  localization  of  any  opacity  may  be  determined  with 
some  accuracy  by  the  following  method :  If  the  observer's 
eye  is  moved  so  that  the  opacity  which  he  sees  lies  nearly  in 
line,  let  us  say,  with  the  lower  edge  of  the  pupil,  when  the 
patient's  eye  is  turned  upward  the  opacity,  if  it  lies  hack  of  the 
pupil,  will  disappear  behind  the  iris,  or  if  it  lies  in  front. 


24  EXAMINATION  OF  THE  EYE  AND  ITS  APPENDAGES. 

it  will  appear  to  move  "upward  from  the  edge  of  the  pupil. 
The  principle  of  parallax  is  here  involved. 

The  behavior  of  the  opacity  with  reference  to  a  brilliant 
point  of  light  which  is  the  reflex  from  the  anterior  surface  of 
the  cornea,  and  which  is  referred  to  a  point  just  back  of  the 
posterior  pole  of  the  lens,  may  be  observed  in  the  same  way. 

The  vitreous  should  be  carefully  scanned  for  fixed  or  float- 
ing opacities  while  the  eye  is  moved  about.  Lesions  in  the 
vitreous  may  be  located  and  followed  at  different  depths  by 
bringing  into  place  convex  lenses  of  the  ophthalmoscope. 

III.  The  details  of  the  fundus  may  now  be  investigated 
by  what  is  known  as  the  direct  method  or  the  method  of  the 
erect  image.  The  patient  and  the  light  should  be  placed 
as  just  described,  and  the  upper  edge  of  the  ophthalmoscope 
placed  on  the  supraorbital  ridge  of  the  observer  with  the  chin 
held  down.  The  light  is  reflected  into  the  pupil  of  the 
patient^s  eye  and  the  observer  approaches  very  near.  If  the 
accommodation  is  relaxed  by  an  attempt  to  look  at  a  distance 
with  both  eyes  open,  the  fundus  will  come  into  view,  if  the 
refraction  of  both  the  patient  and  observer  is  normal.  .  The 
erect  image  thus  seen  will  be  magnified  about  15  times. 

IV.  The  Indirect  Method  or  the  Method  of  the  Inverted 
Image. — The  light  is  thrown  from  the  ophthalmoscope,  held 
at  a  distance  of  about  18  inches,  with  a  -f  3  D.  lens  before  the 
aperture. 

With  the  other  hand  the  lens  used  for  oblique  illumination 
(+lo  D.)  is  held  about  2  inches  from  the  patient's  eye.  An 
inverted  image  will  form  between  the  object  lens  and  the 
ophthalmoscope.     It  is  magnified  about  5  times. 

Choice  of  Method. — The  method  of  the  erect  image  is  to  be 
preferred  for  closer  examination  since  the  enlargement  is 
greater  but  the  field  is  small.  The  use  of  the  ophthalmosco[)e 
for  determining  errors  of  refraction  will  be  described  under 
the  head  of  Errors  of  Refraction. 

The  Fundus. — The  ophthalmoscope  opens  to  one's  view  a 
little  more  than  the  posterior  hemisphere  of  the  internal  sur- 
face of  the  eyeball.  It  is  often  desirable  to  use  a  mydriatic  to 
facilitate  the  examination,    Homatropine  hydrobromate  (2  per 


THE  FUNDUS.  25 

cent.)  or  euphthalmin  (5  per  cent.)  are  the  most  suitable  for  this 
})urpose.  In  carrying  out  a  complete  examination  of  the  fundus 
the  two  landmarks  which  should  be  first  found  are  the  optic 
nerve  (optic  disk,  papilla)  and  the  macula  (yellow  spot).  The 
former  appears  as  an  oval  pinkish-white  disk.  A  pit  with 
sh)ping  sides  is  in  the  centre  (physiological  excavation),  with 
the  mottled  appearance  of  the  lamina  cribrosa  at  its  bottom. 
A  white  ring  of  varying  breadth  (scleral  ring)  surrounds  the 
disk,  and  outside  of  this  more  or  less  pigment  (choroidal  ring). 
From  the  nerve  comes  the  central  artery  of  the  retina  as  a 
single  trunk,  or  already  divided,  and  it  then  divides  and  sub- 
divides on  the  retina.  The  veins  follow  in  general  the  same 
course  as  the  arteries.  The  color,  amount  of  blood-supply, 
sharpness  of  outline,  and  swelling  of  the  disk  shoukl  not  esca])e 
notice.  The  presence  of  an  excavation  with  sharp  sides,  over 
which  the  vessels  seem  to  fall  (cupped  disk),  may  denote  glau- 
coma. The  other  landmark — the  macula — which  is  very  diffi- 
cult to  see  when  the  pupil  is  small,  is  an  area  of  deeper  color 
than  the  surrounding  fundus,  and  shows  a  pit  in  its  centre 
with  a  bright  reflex  (fovea  centralis).  An  examination  can  not 
be  thorough  without  a  careful  investigation  of  this  region, 
whose  integrity  is  so  necessary  to  perfect  vision.  The  retinal 
vessels  should  be  followed  from  the  nerve  over  the  fundus 
and  changes  in  them  noted.  The  general  appearance  of  the 
fundus  is  variable  with  the  amount  of  pigment,  depending  on 
the  complexion  of  the  individual.  When  the  retinal  pigment 
is  plentiful,  a  dark-red,  mottled  background  is  presented  for 
the  retinal  vessels ;  when  scanty,  the  choroidal  vessels  as 
well  are  seen  as  a  network  either  lighter  or  darker  than  the 
background  of  choroidal  pigment.  Remembering  that  the 
retinal  vessels  are  in  the  nerve-fibre  layer,  wiiich  is  practi- 
cally the  inner  layer  of  the  retina,  that  the  retinal  pigment  is 
the  outer  layer  of  the  retina,  and  that  the  choroidal  vessels  lie 
in  the  choroidal  pigment,  the  depth  of  any  lesion  may  be  made 
out  from  these  landmarks.  The  fundus  should  be  searched  in 
all  directions  for  lesions — such  as  blood  in  spots,  splashes,  or 
large  areas,  white  patches  of  exudate,  degeneration,  or  of  ex- 
posed sclera.     Black  masses  of  pigment — retinal  or  choroidal. 


26   EXAMINATION  OF  THE  EYE  AND  ITS  APPENDAGES. 

Tension. — The  proper  way  to  test  the  hardness  of  the  eye- 
ball is  by  making  the  patient  look  down,  and  delicately,  with 
the  two  first  fingers,  press  through  the  upper  lid  until  the 
eyeball  is  felt.  By  alternately  pressing  with  either  finger 
while  the  other  finger  is  held  fixedly  in  contact  with  the  eye- 
ball as  the  surgeon  gets  the  ^'  sense  of  fluctuation  '^  a  judgment 
of  the  tension  is  obtained. 

Degrees  of  Tension. — An  eye  that  is  somewhat  harder  than 
the  normal  is  described  as  having  tension,  T.  +1.  Decided 
rise  of  tension  is  recorded  as  T.  +2  ;  stony  hardness  as  T.  +3. 
Conversely,  T.  — 1,  T.  — 2,  T.  — 3,  denote  varying  degrees  of 
softness.  Instruments  for  recording  the  degree  of  tension 
have  been  devised,  but  are  of  little  practical  value. 

Vision. — The  sense  of  sight  is  divided  into :  I.  Form-sense 
(acuity  of  vision) ;  II.  Color-sense ;  and  III.  Light-sense. 

The  form-sense  may  be  classified  as  (a)  direct  or  central 
vision,  and  (6)  indirect  or  peripheral  vision. 

I.  Acuity  of  Vision. — Distance. — In  order  to  record  with 
exactness  the  acuity  of  («)  direct  or  central  vision  the  employ- 
ment of  letters  has  been  found  the  most  practical  test.  The 
universal  method  is  to  determine  the  smallest  letters  which 
the  patient  can  read  from  a  card  containing  letters  of  various 
sizes  placed  at  a  given  distance.  The  construction  of  such 
a  card  is  based  upon  the  assumption  that,  with  average 
acuity  of  vision,  a  patient  should  normally  recognize  a  letter 
at  any  given  distance  when  the  height  and  breadth  of  that 
letter  subtend  an  angle  of  5'  of  arc,  the  apex  of  which 
angle  is  at  the  patient's  eye.  In  other  words,  if  two  lines  are 
made  to  diverge  from  the  eye  forming  an  angle  between  them 
of  5',  letters  fitted  between  these  lines  at  different  distances 
will  vary  in  size,  but  will  all  form  the  same  size  image  on  the 
retina  and  be  seen  equally  well.  The  letters  on  Snellen's 
card,  which  is  usually  employed,  are  all  of  a  size  determined 
upon  the  principle  just  stated  and  properly  numbered  for  the 
distance  at  which  they  are  placed  in  the  angle. 

Method  of  Recording  Acuity  of  Vision. — Each  eye  should 
be  tested  separately.  With  the  card  placed  in  a  good  light 
^t   a   distance    of   20   f^et   from   the   patient,   the   smallest 


VISION.  27 

letters  which  can  be  read  are  noted.  The  number  over  these, 
which  denotes  the  distance  in  feet  or  metres  at  which  they 
should  be  read,  forms  the  denominator  of  a  fraction  whose 
numerator  is  the  distance  of  the  card  from  the  patient — 
generally,  as  stated,  20  feet  or  6  metres.  Example :  If  the 
number  of  the  line  of  smallest  letters  read  is  40,  the  record 
will  be  V.  =  f^.  When  vision  is  too  poor  to  be  tested  with 
letters,  the  distance  at  which  fingers  may  be  counted  should 
be  noted.  Or,  vision  may  be  reduced  to  perception  of  light 
(p.  1.)  or  may  be  nothing  (V.  =  0).  For  the  illiterate,  forms 
such  as  the  spots  of  playing-cards  or  familiar  objects  may  be 
employed  instead  of  letters. 

Near  Point. — A  card  for  the  purpose  of  testing  vision  at 

Fig.  3. 


The  visual  angle. 

the  near  point  is  constructed  upon  the  same  principles,  but 
various  sizes  of  printers'  type  are  usually  employed  (Jaegei'^s). 
The  record  is  made  for  the  number  of  the  type  read  and  nt 
the  reading  distance,  12  to  14  inches.  The  ability  to  change 
the  refractive  power  of  the  dioptric  media  of  the  eye  is  called 
the  accommodation,  and  lies  in  the  action  of  the  ciliary  muscle, 
which  in  contraction  relaxes  the  tension  on  the  suspensory 
ligament  of  the  lens,  and  the  latter  by  its  inherent  elasticity 
becomes  more  convex,  especially  as  to  its  anterior  surface,  and 
thus  enables  the  focus  for  a  near  object  to  fall  upon  the  retina. 
The  test  for  the  accommodation  consists  in  observing  the 
nearest  point  to  the  eye  at  which  the  print  remains  clear. 
Field  of  Vision* — The  area  of  more  or  less  distinct  vision 


28   EXAMINATION  OF  THE  EYE  AND  ITS  APPENDAGES. 

which  is  available  about  the  object  of  fixation  (6)  {indirect 
vision)  is  called  the  field  of  vision.  The  angular  distances  at 
which  objects  can  be  seen  on  all  sides,  or  the  limits  of  the 
field  of  vision,  are  approximately  :  on  the  temporal  side  95 
degrees,  nasal  65  degrees,  above  65  degrees,  below  70  degrees. 

Fig.  4. 


Field  of  vision  of  ri^ht  eye  as  projected  by  the  patient  on  the  inner  surface  of 
a  hemisphere,  the  pole  of  which  forms  the  object  of  regard :  T,  temporal,  and  N,  nasal 
side  ;  W,  boundary  for  white ;  B,  for  blue ;  R,  for  red  ;  G,  for  green.  Half-diagram- 
matic.   (Landolt.) 

Rough  estimates  may  be  made  by  requiring  the  patient,  with 
the  other  eye  closed,  to  look  steadily  at  the  observer's  oppo- 
site eye  at  about  1  foot  distant,  while  the  points  at  which  the 
hand  or  some  white  object  can  be  followed  on  all  sides  are 
noted  and  compared  with  the  observer's  field.  Another 
method  consists  in  placing  the  patient  before  a  blackboard 


oooo 


29 


Perimeter.  The  examination  may  be  made  with  the  carrier  which  moves  along 
the  semicircle,  or  the  test-objects  may  be  carried  along  this  by  means  of  dark  disks 
attached  to  a  long  handle,  each  disk  containing  in  its  centre  the  test-object.  The 
pMtient's  chin  is  placed  in  the  curved  chin- rest;  the  notched  end  of  the  upright  l)ar 
is  brought  into  contact  with  the  face,  directly  beneath  the  eye  to  be  examined,  whicli 
attentively  fixes  the  centre  of  the  semicircle.  The  other  eye  should  be  covered, 
preferably  with  a  neatly  adjusted  bandage.  The  record  chart  is  inserted  at  the  back 
of  the  instrument,  and,  by  means  of  an  ivory  vernier,  the  examiner  is  enabled  to 
mark  exactly  with  a  pencil  tne  point  on  the  chart  corresponding  to  the  position  on 
the  semicircle  at  which  the  patient  sees  the  test-object.  The  various  marks  are 
then  joined  by  a  continuous  line,  and  a  map  of  the  field  is  obtained. 


and  tracing  with  a  piece  of  chalk  the  limits  of  the  field  while 
the  eye  is  fixed  upon  a  point  directly  in  front.     For  exact 


30  EXAMINATION  OF  THE  EYE  AND  ITS  APPENDAGES. 

measurements  an  instrument  called  the  perimeter  is  employed. 
It  consists  essentially  of  a  rest  for  the  chin  and  a  semicircular 
metal  or  hard  rubber  arc  of  about  1  foot  radius,  so  fixed  that 
when  the  head  is  placed  in  the  rest  the  eye  to  be  examined 
will  be  in  the  centre  of  the  arc.  The  arc  may  be  turned 
about  on  an  axis  which  is  a  line  drawn  between  the  eye  and 
the  centre  of  the  arc  lying  directly  in  front  of  and  on  a  level 
with  the  eye.  By  revolving  the  arc  about  and  passing  a 
white  object  on  it  away  from  the  central  point,  upon  which 
the  eye  is  fixed,  the  whole  field  may  be  covered.  The  field 
for  one  eye  is  called  the  monocular  field  of  vision  ;  the  field 
common  to  both  is  called  the  binocular  field.  One  should 
observe  concentric  contraction  of  the  field  of  vision,  irregular 
contraction,  and  isolated  defects  (scotomata).  When  there  is 
no  vision  in  the  defective  part  of  the  field,  the  scotoma  is 
absolute;  when  the  vision  is  diminished,  relative.  If  one- 
half  of  the  field  is  defective,  the  condition  is  known  as  hemi- 
anopsia. This  is  due  to  causes  local  in  the  eye  or  to  lesions 
in  the  chiasm,  optic  tracts,  optic  radiation,  or  cortex  of  the 
occipital  lobe. 

II.  Color-sense. — A  defect  in  the  color-perception  may  be 
either  congenital  or  acquired.  In  the  latter  case  the  defect 
may  be  only  central  (central  color  scotoma).  The  best  method 
of  testing  color-perception  is  by  the  use  of  skeins  of  colored 
worsted  (Holmgren's  test).  A  red  skein  is  laid  on  a  table, 
and  the  patient  is  required  to  choose  others  which  resemble  it 
in  color.  For  railroad  and  marine  employees  tests  are  also 
made  with  lanterns  which  show  colored  lights  (Thomson's  or 
Williams'  lanterns).  Colors  are  not  seen  so  far  from  the  point 
of  fixation  as  white — i.  e.,  the  field  for  colors  is  smaller. 
Green  has  the  smallest  field ;  then  red,  blue,  and  white  in  the 
order  named. 

III.  Light-sense  is  the  pow'er  of  the  eye  to  appreciate  varia- 
tion in  the  intensity  of  illumination.  An  instrument  called 
a  photometer  may  be  used  in  measuring  differences  of  illumi- 
nation.    Diseases  such  as  retinitis  may  affect  the  light-sense. 

Muscles. — Only  the  external  muscles  of  the  eyeball  are  in- 
cluded under  this  caption.     Although  the  methods  of  detect- 


mSEASES  OF  THE  LACHRYMAL  APPARATUS.        31 

ing  error  of  motility  will  be  referred  to  later,  it  is  well  to  test 
the  action  of  the  muscles  roughly  at  this  point.  The  excur- 
sion of  each  eye,  while  following  the  finger  in  every  direction, 
should  be  tested  and  limitations  noted  (paralysis  or  paresis). 
There  should  be  no  deviation  of  either  line  of  vision  from  the 
object  of  fixation  (strabismus). 

If  one  eye  is  covered  with  a  card  and  the  other  eye  fixed 
upon  any  object,  there  should  be  no  deviation  of  the  covered 
eye,  and  it  should  make  no  movement  when  uncovered  (cover- 
test  for  insufficiency).  Both  eyes  should  fix  upon  the  same 
object  and  the  two  images  should  fuse  (binocular  vision).  If 
both  eyes  do  not  fix  upon  the  same  object,  double  images  are 
likely  to  result  (diplopia). 

QUESTIONS. 

Describe  the  method  of  examining  the  conducting  lachrymal  apparatus. 
State  points  to  be  observed  in  examining  the  lids,  conjunctiva,  and  sclera. 
What  is  oblique  illumination  ? 

Give  the  forms  of  conjunctival  discharge  and  of  congestion  of  the  eyeball. 
Describe  examination  of  the  cornea,  anterior  chamber,  iris,  and  lens. 
Explain  the  four  methods  of  using  the  ophthalmoscope. 
Describe  the  fundus. 
Give  test  of  tension. 

Describe  method  of  testing  the  acuity  of  vision  at  distance  and  at  near 
point. 

What  is  the  field  of  vision? 

How  is  color-sense  tested  ? 

Give  superficial  tests  for  the  ocular  muscles. 


CHAPTER  II. 

DISEASES  OF  THE  LACHRYMAL  APPARATUS. 

Diseases  of  the  lachrymal  apparatus  are  classified  as  dis- 
eases of  the  secreting  and  diseases  of  the  conducting  por- 
tions. 

DISEASES  OF  THE  SECRETING  PORTION. 

The  secreting  portion  consists  of  the  lachrymal  gland,  in- 
cluding the  accessory  gkmd  of  Rosenmuller. 

The  lachrymal   gland  is  rarely  the   subject  of  disease. 


32        DISEASES  OF  THE  LACHRYMAL  APPARATUS. 

Acute  nonsuppurative  inflammation  (dacryoadenitis),  some- 
times called  '^  mumps,"  and  acute  suppuration  (abscess),  do 
occasionally  occur.  It  may  also  be  involved  in  a  chronic 
inflammation,  causing  hypertrophy.  A  cystic  distention  of 
one  of  the  ducts  (dacryops)  is  also  described.  Tumors  of  the 
lachrymal  gland  are  not  unknown — e.  g.,  carcinoma,  sarcoma, 
cysts,  tuberculosis,  and  syphilis.  It  may  become  prolapsed 
downward,  when  it  may  be  seen  and  felt.  Fistula  is  of  rare 
occurrence. 

DISEASES  OF  THE  CONDUCTING  PORTION. 

The  conducting  portion  consists  of  the  punctay  canaliculiy 
lachrymal  saCj  lackrymal  (nasal)  duct 

Malposition  or  stenosis  (atresia)  of  the  puncta  or  canaliculi 
may  be  congenital.  The  most  common  condition,  however, 
is  displacement  of  the  puncta  by  turning  out  of  the  lids 
(ectropion),  so  that  they  do  not  lie  against  the  eyeball.  This 
is  produced  by  thickening  of  the  lid  in  chronic  diseases,  re- 
laxation in  old  age  and  in  facial  paralysis,  or  by  cicatricial 
contraction  after  traumatism.  Foreign  bodies,  as  an  eyelash, 
leptothrix,  or  calcareous  deposits  and  wounds  may  occlude 
the  lumen. 

Symptoms. — The  natural  result  of  stenosis  or  malposition 
is  epiphora — the  patient  complaining  of  a  watery  eye,  tears 
flowing  on  the  cheek,  especially  in  wind  or  in  cold  weather. 

Treatment. — For  congenital  as  well  as  acquired  stenosis 
treatment  is  often  unsatisfactory.  If  the  punctum  alone  is 
affected,  it  may  sometimes  be  opened,  enlarged,  or  dilated 
with  success.  For  malposition,  due  to  hypertrophy  of  the 
lid,  treatment  consists  in  astringent  applications  to  the  con- 
junctival surface,  such  as  nitrate  of  silver,  1  to  2  per  cent, 
solutions. 

DISEASES  OF  THE  LACHRYMAL  SAC. 

The  lachrymal  sac  has  a  small  inlet  through  the  canaliculi 
and  an  outlet  through  the  nasal  duct.  Mechanical  interfer- 
ence with  the  flow  of  tears  from  the  sac  into  the  nose  tends 


CHRONIC  DACRYOCYSTITIS.  33 

to  distention  and  disease  of  the  sac.  The  diseases  of  the  sac 
are  classified  as  (a)  Chronic  catarrhal  dacryocystitis ;  later  (6) 
Acute  suppurative  dacryocystitis  {cibscess  of  the  lachrymal  sac) 
may  supervene. 

CHRONIC   DACRYOCYSTITIS. 

Synonym. — Blennorrhoea  of  the  lachrymal  sac. 

Definition. — A  chronic  catarrhal  inflammation  of  the  mucous 
lining  of  the  lachrymal  sac. 

Etiology. — The  underlying  cause  is  stricture  of  the  nasal 
duct,  usually  accompanying  nasal  diseases,  such  as  catarrh, 
polypi,  or  traumatic  disturbance  of  the  bone,  with  damming 
back  of  the  tears  and  distention  of  the  sac  (mucocele).  The 
stricture  is  generally  either  at  the  upper  or  the  lower  end  of 
the  duct.  The  mucous  membrane  of  the  sac  thus  becomes 
diseased  from  the  presence  of  the  accumulated  discharge. 

Subjective  Sjrmptoms. — The  patient  complains  of  epiphora 
and  troubles  referred  to  the  lids,  which  come  from  the  ever- 
present  complicating  chronic  conjunctiv^itis. 

Objective  Ssmiptoms. — The  distended  sac  may  be  seen  and 
felt  as  an  elastic  tumor.  When  pressure  is  made  upon  it,  the 
contents  usually  pass  out  through  the  puncta,  or  are  forced  into 
the  nose  through  the  stricture  of  the  nasal  duct.  The  lids 
are  red,  swollen,  showing  more  or  less  discharge  at  the  edge 
from  the  conjunctivitis  and  blepharitis,  and  the  caruncle  is 
swollen. 

Course. — Such  a  condition  in  the  sac  may  exist  for  years, 
but  abscess  is  always  liable  to  occur,  and  the  disease  does  not 
tend  to  improve.  In  long-standing  cases  necrosis  of  the  ad- 
joining bone  may  ensue. 

Diagnosis. — The  epiphora  and  discharge  of  mucopurulent 
fluid  through  the  puncta  on  pressure  over  the  sac  make  the 
diagnosis  unmistakable. 

Palliative  treatment  consists  in  the  instillation  of  astrin- 
gents— e.  g.j  zinc  sulphate  (0.3  per  cent.)  or  alum  (0.5  per 
cent.) — immediately  after  emptying  the  sac  by  pressure,  and  in 
treating  the  primary  nasal  disease  especially  in  the  region  of 

o — hi.  ii. 


34        DISEASES  OF  THE  LACHRYMAL  APPARATUS. 

the  opening  of  the  nasal  duct.  The  sac  may  be  syringed  with 
astringent  sohitions,  such  as  nitrate  of  silver  (0.5  to  1  per  cent.). 
Operative  Treatment. — I.  Slitting  the  canaliculus  and  cut- 
ting the  stricture  in  the  nasal  duct  are  accomplished  as  fol- 
lows :  A  small,  narrow,  probe-pointed  knife  (canaliculus- 
knife),  with  a  long,  slightly  curved  shank,  is  introduced 
usually  into  the  lower  punctum.  After  entering  with  the 
point  downward,  the  knife  is  turned  in  a  horizontal  direction 
and  passed  along  the  canaliculus,  with  the  cutting  edge  in- 
ward toward  the  eyeball,  while  the  lid  is  drawn  in  the  oppo- 
site direction  with  the  finger  and  held  quite  taut.  The  knife 
should  be  passed  through  the  lachrymal  sac  until  it  meets  the 
lachrymal  bone.  With  the  point  pressed  against  the  bone, 
the  handle  should  be  raised  until  vertical,  and  the  canaliculus 
thus  fully  slit,  while  the  point  is  pushed  down  through  the 

Fig.  6. 


Weber's  canaliculus-knife. 

nasal  duct  into  the  inferior  meatus  of  the  nose.  The  direc- 
tion of  the  knife  should  be  toward  the  groove  between  the  ala 
of  the  nose  and  the  cheek.  The  injection  into  the  sac  of  a 
solution  of  adrenalin  chloride  (1  :  10,000)  and  cocaine  hydro- 
chlorate  (2  per  cent.)  will  facilitate  the  operation  by  their  vaso- 
constricting  action.  Immediately  after  withdrawing  the  knife 
the  whole  tract  must  be  syringed  with  a  mild  antiseptic  solu- 
tion, such  as  boric  acid  (3  per  cent.).  The  next  step  consists 
in  passing  a  probe  (usually  the  largest  possible)  through  the 
nasal  duct  into  the  nose,  and  allowing  it  to  remain  in  place  for 
a  few  minutes.  Bowman,  Theobald,  and  Weber  probes  are  the 
common  styles,  and  they  vary  in  diameter  from  1  to  4  mm. 
To  prevent  the  stricture  from  reforming,  the  probing  should 
be  continued  at  first  every  other  day,  and  later,  at  longer 
intervals,  for  several  weeks  or  months,  depending  on  the 
character  and  behavior  of  the  stricture.     The  operation  and 


ASSCSSS  OF  THE  LACHRYMAL  SAC. 


36 


probing  are  painful,  and  the  results  are  not  always  satisfac- 
tory, at  least  as  far  as  the  epiphora  is  concerned,  although  the 
slitting  of  the  canaliculus  alone  will  usually  prevent  danger 
of  abscess.  In  infants  operative  measures  should  be  under- 
taken cautiously,  since  many  cases  recover  under  palliative 
treatment. 

II.  The  introduction  into  the  nasal  duct  of  lead  or  silver 
styles  which  are  left  in  place  indefinitely  was  formerly  much 
practised. 

III.  In  obstinate  cases  and  in  those  where  operative  pro- 
cedures on  the  eyeball  are  contemplated  and  infection  feared, 


Fig.  7. 


Bowman's  probes  in  position.    (Reeve.) 

the  sac  should  be  destroyed.  It  is  exposed  by  a  skin  incision 
and  cauterized  or  dissected  out.  The  epiphora  is  not  dis- 
tressing, but  excision  of  the  lachrymal  gland  has  been  advo- 
cated. 

ABSCESS    OF   THE    LACHRYMAL    SAC. 

Synonyms. — Purulent  dacryocystitis ;  Phlegmon. 
Definition. — Acute  suppurative  inflammation  of  the  sac  and 
surrounding  tissues. 


36        DISEASES  OF  THE  LACHRYMAL  APPARATUS. 

Etiology. — Chronic  dacryocystitis  is  always  the  forerunner 
of  abscess.     Infection  is  the  immediate  cause. 

Pathology. — The  pyogenic  germs  which  are  always  present 
in  the  sac  may  excite  acute  inflammation  in  the  sac  and  walls, 
with  the  same  pathogenesis  as  elsewhere  in  the  body. 

Subjective  Symptoms. — The  patient  who  has  been  troubled 
with  epiphora  or  dacryocystitis  is  suddenly  attacked  with 
severe  throbbing  pain  in  the  region  of  the  sac. 

Objective  Symptoms. — The  skin  becomes  red,  tense,  swollen, 
and  tender.  The  lids  also  are  swollen,  and  there  may  be 
constitutional  disturbances.  If  not  incised,  the  abscess  points 
and  bursts  on  the  skin  surface  and  may  leave  a  permanent 
fistulous  tract  connecting  with  the  sac. 

Diagnosis. — The  involvement  of  the  lachrymal  sac  is  estab- 
lished by  the  situation  of  the  abscess  and  the  history  of 
epiphora,  but  the  condition  might  be  mistaken  for  abscess  of 
the  lid  or  for  processes  involving  the  bone  in  the  vicinity. 

Prophylactic  treatment  consists  in  treating  the  dacryocystitis. 

Active  Treatment. — When  the  abscess  is  forming,  hot  fo- 
mentations or  poultices  are  indicated.  When  the  tumor  softens, 
it  should  be  promptly  and  freely  incised  through  the  skin  and 
the  cavity  syringed  and  packed  with  gauze.  The  wound  is 
then  dressed  daily  on  general  surgical  principles.  If  excessive 
granulations  form,  they  may  be  treated  by  scraping  or  by 
nitrate  of  silver  stick.  When  all  reaction  has  subsided,  the 
canaliculus  should  be  slit  and  the  nasal  duct  probed  if  possible, 
in  order  to  prevent  recurrence,  which  is  liable  to  take  place. 

QUESTIONS. 

What  lesions  may  occur  in  the  secreting  portion  of  the  lachrymal  apparatus? 
What  are  the  causes,  symptoms,  and  treatment  of  malposition  or  stenosis  of 
the  puncta  and  canaliculi? 

How  are  diseases  of  the  lachrymal  sac  divided  ? 
What  are  the  causes  of  chronic  dacryocystitis  ?' 
What  are  the  symptoms  and  complications? 
Describe  the  palliative  and  operative  treatment. 
Describe  abscess  of  the  lachrymal  sac. 
What  results  may  follow  stricture  of  the  nasal  duct? 


DISEASES  OF  THE  LIDS.  37 

CHAPTER   III. 
DISEASES  OF  THE  LIDS. 
BLEPHARITIS   MARGINALIS. 

Synonyms. — Blepharitis  ciliaris ;  Tinea  tarsi ;  Blepharo- 
adenitis. 

Definition. — A  chronic  inflammation  of  the  edge  of  the  eye- 
lids accompanied  by  congestion,  thickening,  ulceration,  and 
formation  of  crusts  and  scales. 

Etiology. — The  underlying  cause  is  often  a  conjunctivitis 
with  improper  care  in  cleansing  the  roots  of  the  lashes  where 
the  discharge  collects.  Errors  of  refraction  are  indirectly 
responsible  in  some  cases.  Other  causes  are  improper  mode 
of  life,  depression  in  the  general  health,  late  hours,  smoke, 
and  dust.  It  complicates  lachrymal  disease  and  may  follow 
the  exanthemata. 

Dermatological  Classification. — The  disease  assumes  the  form 
oi (a)  sehorrhwa,  where  the  sebaceous  glands  are  affected,  form- 
ing scales  or  yellow  crusts ;  (h)  sycosis,  in  which  case  there  is 
suppuration  in  the  hair-bulbs ;  (c)  eczema,  being  often  asso- 
ciated with  eczema  of  the  face  in  children. 

Clinical  Classification. — The  disease  is  commonly  divided 
into  ulcerative  and  nonulcerative  blepharitis. 

Ssrmptoms. — The  congestion  along  the  roots  of  the  lashes  is 
often  the  only  symptom  (hypersemia  marginalis).  This  comes 
and  goes  at  the  least  provocation,  such  as  eyestrain,  late 
hours,  exposure  to  wind,  etc.  In  more  marked  form  there 
will  be  formation  of  scales  and  crusts  (squamous  blepharitis). 
In  other  cases  minute  pustules  (pustular  blepharitis)  are  found, 
and  when  these  rupture,  hard  crusts  and  scabs  form,  under 
which  ulcerations  are  found  (ulcerative  blepharitis). 

Course. — The  disease,  which  is  most  common  in  children, 
extends  over  many  years  and  ultimately  results  in  complete 
loss  of  the  eyelashes  (madarosis),  with  the  edge  of  the  lid 
thickened  and  everted  (tylosis). 


38  DISEASES  OF  THE  LIDS. 

Treatment,  which  is  tedious,  consists  in  correcting  errors  of 
refraction,  reforming  the  mode  of  life,  and  attending  to  con- 
stitutional disturbances. 

Local  Treatment. — Strict  cleanliness  should  be  observed. 
The  edges  of  the  lids  must  be  washed  with  soap  and  water 
or  solutions  of  borax  or  bicarbonate  of  sodium  until  free  from 
crusts.    Ointments  may  then  be  applied,  such  as  the  following : 

^,  Hydrargyri  oxidi  flavi,  0.15; 

Petrolati,  10.00. 

M.  et  ft.  ung. 
Sig. — Rub  on  the  edge  of  the  eyelids  every  night. 

One  may  also  use  ointments  of  hydrargyrum  ammoniatum 
(1  per  cent.),  hydrargyrum  rubrum  (1  per  cent.),  or  ichthyol 
(5  per  cent.).  In  ulcerative  cases  nitrate  of  silver  solutions 
(1  to  2  per  cent.)  or  even  the  stick  of  nitrate  of  silver  are 
indicated.  When  pustules  form  about  the  hair-follicles,  the 
cilia  should  be  pulled  out.  Astringents  such  as  zinc  sulphate 
(0.3  per  cent.)  or  nitrate  of  silver  (1  per  cent.)  should  be  used 
to  cure  the  complicating  conjunctivitis. 

HORDEOLUM. 

Synonym. — Stye. 

Definition. — An  acute  circumscribed  suppurative  inflam- 
mation  beginning  in  the  glands  at  the  margin  of  the  lid. 

Etiology. — The  presence  of  blepharitis,  disturbances  of 
digestion,  impaired  vitality,  and  eyestrain.  The  immediate 
cause  is  infection  with  pyogenic  germs. 

Pathology. — On  account  of  the  numerous  glandular  struct- 
ures, the  edge  of  the  lid  is  a  favorable  place  for  the  entrance 
of  infection.     It  is  also  liable  to  slight  abrasions  by  rubbing. 

Symptoms. — Itching  and  burning  sensations  followed  by  a 
red  and  swollen  area  at  the  edge  of  the  lid.  Later  the  abscess 
forms,  points,  and  discharges.  There  is  often  extensive 
oedema  of  the  lid  out  of  proportion  to  the  size  of  the  lesion. 

Course. — Styes  run  their  course  in  from  three  days  to  a  week 
or  more,  and  are  often  repeated  one  after  another.     At  times 


CHALAZION. 


39 


one  will  not  reach  the  suppurative  stage,  but  become  aborted 
or  remain  as  a  hard  swelling  ("  blind  stye  "). 

Treatment. — The  digestive  tract  should  be  treated  and  con- 
stitutional treatment  instituted.  Bits  of  ice  held  against  the 
beginning  stye  may  abort  it.  Ointments  of  red  or  yellow 
oxide  of  mercury  (1  per  cent.)  may  be  applied.  Later  hot 
fomentations  will  encourage  suppuration.  Early  incision  will 
cut  short  the  course. 

CHALAZION. 

Synonyms. — Tarsal  tumor ;  Meibomian  cyst. 
Definition. — A  chronic  affection  of  the  Meibomian  glands 
with  the  formation  of  a  hard  swelling  in  the  lid. 

Fig.  8. 


Chalazion.    (Reeve.) 


Etiology. — Chalazia  are  regarded  by  some  as  due  to  infec- 
tion, but  in  many  cases  the  direct  cause  is  the  stoppage  of  a 
Meibomian  duct  and  the  accumulation  of  discharge  in  the 
gland. 

Pathology. — The  process  seems  to  be  a  chronic  inflammation 
with  the  production  of  granulation-like  material  originating 
in  the  Meibomian  gland.     Under  the  microscope  these  tumors 


40  DISEASES  OF  THE  LIDS. 

in  the  typical  stage  show  scant  connective-tissue  stroma  with 
many  round  cells  and  without  true  capsule. 

Subjective  Symptoms.— The  patients  usually  have  little  com- 
plaint except  on  account  of  the  appearance  of  the  swelling. 
The  inflammatory  symptoms  which  may  occur  at  the  begin- 
ning and  the  roughened  condition  of  the  lid  occurring  later 
may  create  more  or  less  irritation. 

Objective  Symptoms. — A  chalazion  appears  as  a  round  or 
elongated  tumor  varying  in  size  up  to  that  of  a  walnut.  It 
is  firmly  adherent  to  the  tarsal  cartilage  with  the  skin  usually 
freely  movable  over  it.  On  the  conjunctival  aspect  a  dark 
spot  generally  shows  in  the  tarsus. 

Course. — A  chalazion  may  begin  with  symptoms  of  horde- 
olum  and   later    lose    inflammatory   signs,   or   may   appear 

Fig.  9. 


Desmarres'  chalazion  forceps. 

without  inflammation.  At  times  the  adjoining  tissue  is  in- 
volved in  chronic  inflammatory  infiltration.  Later  the  centre 
of  the  chalazion  breaks  down  into  a  clear  or  yellowish  fluid, 
and  the  degeneration  continues  until  the  whole  mass  becomes 
a  cyst  with  thickened  walls.  Generally  the  fluid  escapes 
through  a  spontaneous  opening  on  the  inner  aspect  of  the  lid. 
This  soon  closes,  and  about  it  granulations  form  sometimes 
as  large  polypoid  masses.  Chalazia  are  likely  to  be  multiple 
and  their  course  is  protracted.  They  often  spontaneously 
disappear. 

Treatment. — Hot  fomentations  may  be  tried  with  massage. 

Radical  treatment  consists  in  curetting  or  in  excision.  In 
the  former  procedure,  a  vertical  incision  is  made  on  the  inner 


ENTROPION,  41 

or  conjunctival  side,  and  the  granulation-masses  are  thor- 
oughly scraped  out  with  a  small  sharp-  or  serrated-edged 
spoon  (Meibomian  scoop).  The  sac  refills  with  blood,  which 
is  absorbed  in  a  few  days.  This  operation  may  require  repe- 
tition. A  more  satisfactory  method  consists  in  making  a 
liberal  incision  under  aseptic  conditions  through  the  skin  over 
the  tumor  parallel  to  the  edge  of  the  lid.  The  mass  may  then 
be  dissected  out,  using  the  knife  and  scissors.  The  chalazion 
with  the  region  of  the  lid  about  it  should  be  clamped  oif  by 
an  instrument  (Desmarres'  clamp)  consisting  of  a  horn  plate 
and  a  ring  on  opposite  arms  like  a  forceps.  This  will  pre- 
vent troublesome  hemorrhage  and  fix  the  tumor.  One  or 
more  stitches  are  generally  desirable  after  the  bleeding  has 
stopped.  An  antiseptic  powder,  as  iodoform  or  aristol,  may 
be  used  as  a  dressing  and  covered  with  court  plaster. 

ENTROPION. 

Definition. — A  condition  in  which  the  edge  of  the  eyelid  is 
turned  inward  against  the  eyeball. 

Etiology. — The  common  cause  of  entropion  is  cicatricial 
contraction  of  the  palpebral  conjunctiva  {cicatricial  entropion). 
This  is  generally  produced  by  trachoma,  but  may  be  due  to 
wounds  or  burns.  Entropion  may  also  be  due  to  a  spasmodic 
condition  of  the  orbicularis  of  the  lower  lid  in  elderly  people 
with  lax  condition  of  the  soft  parts  (spasmodic  entropion). 
A  similar  condition  appears  in  children  when  there  is  great 
photophobia  such  as  accompanies  ulcers  of  the  cornea. 

Symptoms. — The  most  serious  consequence  of  entropion  is 
the  brushing  of*  the  lashes  against  the  eyeball  (trichiasis), 
which  leads  to  irritation  and  congestion  of  the  eyeball  and 
ulceration  of  the  cornea. 

Treatment. — For  spastic  entropion,  if  temporary,  the  skin 
of  the  lid  can  be  pulled  down  toward  the  cheek  by  adhesive 
plaster  or  may  be  folded  by  taking  a  long  stitch.  In  trichiasis 
with  the  presence  of  only  a  few  inturned  lashes,  these  may  be 
pulled  out  at  intervals  or  destroyed  by  electrolysis.  But  in 
marked  cases  of  cicatricial  entropion  operative  treatment  is 


42  DISEASES  OF  THE  LIDS. 

indicated.  The  simplest  method  consists  in  excising  an  ellip- 
tical piece  of  skin  of  the  lid  and  closing  the  opening  with 
sutures  (Graefe's  operation).  This  procedure  is  applicable  to 
mild  cases,  and  may  also  be  applied  to  persistent  spastic  entro- 
pion. For  marked  cases  many  different  operations  have  been 
employed.  They  are  for  the  most  part  variations  of  the  fol- 
lowing procedures  :  An  elliptical  piece  of  skin  is  excised  from 
the  lid  with  the  underlying  muscle.  If  there  is  much  in- 
curving of  the  tarsal  cartilage,  a  wedge-shaped  groove  is  cut 
horizontally  in  the  middle  of  the  tarsus  and  sutures  are  passed 
through  the  skin  and  cut  edges  of  the  tarsus  (Streatfeild-Snellen's 

Fig.  10. 


Jaesclie-Arlt's  operation  for  trichiasis:  1,  intermarginal  incision;  2,  3,  positions 
of  the  second  and  third  incisions,  between  which  the  integument  is  removed. 
(Czermak.) 

operation).  Instead  of  grooving  the  tarsal  cartilage,  a  good 
effect  is  obtained  by  splitting  the  margin  of  the  lid  length- 
wise, being  careful  to  leave  all  the  cilia  and  hair-bulbs  on  the 
outer  flap.  This  may  be  left  to  granulate,  but  the  skin  wound 
is  sutured  (Jaesche-Arlt's  operation).  A  narrow  strip  of  skin 
(Hotz)  or  mucous  membrane  (Van  Millengen)  without  a 
pedicle  may  be  fitted  into  the  groove  at  the  lid  margin  and 
will  attach  itself.  In  connection  with  the  above  operations  it 
is  of  great  advantage  at  times  to  lengthen  the  palpebral  fissure 
at  the  outer  canthus  (canthoplasty).  This  is  done  by  a  single 
cut  with  the  scissors  and  by  passing  sutures  between  the  cut 
edges  of  the  conjunctiva  and  skin. 


ECTROPION— PTOSIS.  43 

ECTROPION. 

Definition. — A  rolling  out  of  the  lid — the  opposite  of  en- 
tropion. 

Etiology. — This  condition  is  largely  due  to  thickening  of 
the  conjunctiva  and  margin  of  the  lid,  or  to  cicatricial  con- 
traction of  the  skin  following  wounds,  burns,  ulceration,  or 
caries  of  the  orbital  margin.  It  also  occurs  from  relaxation 
of  the  lid  in  elderly  persons  or  in  paralysis  of  the  orbicu- 
laris. 

Symptoms. — Ectropion  is  unsightly,  exposing  as  it  does 
more  or  less  of  the  conjunctiva.  Epiphora,  chronic  conjunc- 
tivitis, and  irritation  are  complained  of.  The  lower  lid  is 
the  more  frequently  affected. 

Treatment. — When  recent,  moderate  in  degree,  and  due  to 
hypertrophy  of  the  conjunctiva,  applications  of  nitrate  of 
silver  (1  to  4  per  cent.)  to  the  conjunctival  surface  may 
give  relief.  In  advanced  and  marked  cases  the  hypertro- 
phied  tissue  may  be  excised.  When  ectropion  is  due  to 
cicatricial  contraction,  relief  is  obtained  only  from  some 
form  of  operation.  Snellen's  operation  consists  in  passing  a 
suture  with  two  needles,  each  of  which  is  entered  inside  the 
lower  lid  and  comes  out  through  the  skin  on  the  cheek,  leav- 
ing a  loop  on  the  conjunctival  surface.  The  ends  are  then 
tightly  tied  on  the  cheek,  and  the  cicatricial  bands,  w^hich 
result,  tend  to  roll  the  lid  inward.  In  marked  cases  a  plastic 
operation,  generally  by  the  use  of  sliding  flaps,  is  necessary  in 
order  to  relieve  the  tension  of  the  cicatrix  on  the  lid.  Short- 
ening the  palpebral  fissure  by  joining  together  a  portion  of 
the  upper  and  lower  lids  at  the  outer  canthus  (tarsorrhaphy) 
may  be  advisable. 

PTOSIS. 

Definition. — A  drooping  of  the  upper  lid. 

Etiology. — Ptosis  may  be  due  to  paralysis  or  insufficiency 
of  the  levator  palpebrse.  It  occurs  either  in  the  congenital 
form,  when  it  is  usually  bilateral,  or  in  the  acquired  form,  when 
it  is  generally  unilateral.    In  the  latter  case  especially,  it  may 


44 


DISEASES  OF  THE  LIDS. 


be  associated  with  paralyses  of  other  muscles  supplied  by  the 
third  nerve,  such  as  are  due  to  syphilis  or  diseases  of  the 
brain.  There  are  still  other  cases  due  to  mechanical  causes, 
such  as  increased  volume  of  the  lid  with  trachoma,  tumors, 
etc.     Forceps  injuries  at  birth  are  not  unknown  as  a  cause. 

Symptoms. — The  upper  lid  will  cover  the  pupil  in  marked 
ptosis,  and  the  patient  will  attempt  to  raise  the  lid  by  contrac- 

FlG.  11. 


Panas'  operation :  A,  A',  central  sutures ;  B,  B',  lateral  sutures.    (Nettleship.) 


tion  of  the  frontalis  muscle,  holding  the  head  well  back,  thus 
giving  the  characteristic  expression. 

Treatment. — If  ptosis  is  due  to  paralysis  or  to  mechanical 
causes,  the  constitutional  and  local  measures  may  avail.  If 
the  ptosis  is  permanent,  and  especially  in  the  congenital  cases, 
operative  procedures  are  indicated.  The  underlying  principle 
involved  in  nearly  all  the  operations  is  the  attempt  to  connect 
the  upper  lid  more  directly  with  the  occipitofrontalis  muscle, 


iNSVniES  OF  TSE  LtDS. 


45 


and  thus  exaggerate  the  action  of  that  muscle  in  raising  the 
lid.  The  simplest  method  (Graefe's  operation)  is  to  excise  an 
elliptical  piece  of  skin  with  the  underlying  tissue  of  the  lid  and 
suture  the  cut  edges  of  the  wound.  The  Pagenstecher  opera- 
tion consists  in  using  a  suture  with  two  needles,  each  of  wliich 
is  passed  from  the  edge  of  the  lid  up  under  the  skin  and 
brought  out  near  the  eyebrow.  The  ends  are  then  tied, 
and  the  cicatricial  bands,  which  form  along  the  lines  of  the 
sutures,  serve  to  connect  the  lid  with  the  frontalis  muscle. 
These  two  methods  are  applicable  only  to  the  mild  cases,  and 
are  not  always  highly  satisfactory.  The  Panas  method  con- 
sists in  dissecting  a  flap  of  skin  from  the  upper  lid  in  the 

Fig.  12. 


Panas'  operation,  after.    (Nettleship.) 


form  of  a  tongue  which  points  upward.     This  is  drawn  up 
with  sutures  underneath  the  undermined  skin  of  the  eyebrow. 


INJURIES  OF  THE  LIDS. 

Wounds. — Especial  danger  attends  wounds  of  the  lids  from 
the  fact  that  disturbance  in  their  function  of  covering  the 
eyeball  is  serious.     All  wounds  should  be  carefully  sutured  on 


46  DISEASES  OF  THE  LIDS. 

both  the  conjunctival  and  skin  side.     They  heal  kindly,  as 
a  rule. 

Burns. — When  extensive,  burns  are  likely  to  cause  contrac- 
tions and  adhesions,  resulting  in  entropion,  ectropion,  or  sym- 
blepharon. 

MISCELLANEOUS  DISEASES  OF  THE  LIDS. 

Emphysema. — An  inflation  of  the  subcutaneous  tissue  of  the 
lids  with  air  takes  place  when  air  is  forced  through  a  fracture 
of  the  walls  of  the  orbit,  which  establishes  a  communication 
with  the  nose  or  accessory  sinuses.  The  appearances  are  those 
of  simple  oedema,  but  a  peculiar  crackling  sensation  is  experi- 
enced on  palpation.  The  history  of  an  injury  and  violent 
blowing  of  the  nose  confirm  the  diagnosis.  It  disappears 
under  a  bandage. 

Ecchymosis  (Black  Eye). — The  settling  of  blood  in  the 
lid  after  contusion  is  favored  by  the  loose  subcutaneous 
tissue.  In  fractures  at  the  base  of  the  skull  it  occurs  in  the 
lower  lid. 

Treatment. — Ice  applications  in  the  first  few  hours  should 
be  followed  by  hot  fomentations. 

CEdema  of  the  lids  is  a  symptom  common  after  injuries, 
insects'  bites,  inflammatory  action,  like  hordeolum  or  dacryo- 
cystitis, and  occurs  as  angioneurotic  oedema,  from  urticaria,  in 
myxoedema,  nephritis,  cardiac  disease,  or  is  idiopathic.  It 
may  be  associated  with  severe  conjunctivitis  and  deep-seated 
inflammations  of  the  eyeball  and  orbit. 

Abscess  of  the  Lid. — Generally  traumatic.  Should  be  in- 
cised when  pus  has  formed. 

Syphilis  only  rarely  appears  on  the  lids.  It  may  occur  as 
chancre,  mucous  patch  of  the  conjunctiva,  gumma,  or  tertiary 
ulcer. 

Lupus  is  found  on  the  lid,  and  vaccine  ulcers  are  de- 
scribed. 

Blepharospasm  is  an  involuntary  contraction  of  a  part  or 
whole  of  the  orbicularis  muscle. 

Varieties. — It  occurs  as  clonic  or  tonic  spasm.     In  its  sim- 


TUMORS  OF  THE  LID.  47 

plest  form  it  appears  as  a  fibrillary  twitching  of  a  part  of  the 
lid  which  sometimes  annoys  and  alarms  the  patient.  It  may 
take  the  form  of  continual  winking  (nictitatio).  This  usually 
occurs  in  children  as  the  result  of  irritation  from  the  con- 
junctiva and  is  often  choreic  in  nature.  Spasmodic  contractions 
of  the  orbicularis  are  also  associated  with  tic  douloureux,  or 
may  be  of  hysteric  origin. 

Blepharospasm  may  also  appear  in  diseases  producing  irri- 
tation, such  as  phlyctenular  keratitis. 

Lagophthalmos  is  a  condition  in  which  the  lids  can  not  be 
completely  closed,  and  is  due  to  exophthalmos,  injuries,  par- 
alysis of  the  orbicularis,  or  contractions  of  the  lid. 

Phthiriasis  Ciliorum. — Pediculi  pubis  occasionally  deposit 
eggs  on  the  lashes  and  the  insects  themselves  will  be  found 
buried  in  the  lid  margin. 

Diseases  of  the  Skin  of  the  Lid. — The  skin  is  the  seat 
of  various  diseases,  such  as  erythema,  eczema,  erysipelas, 
herpes  zoster,  and  syphilis. 

Epicanthus  is  a  congenital  deformity  in  the  form  of  a  fold 
of  skin  which  extends  from  the  inner  end  of  each  eyebrow  to 
the  side  of  the  nose,  covering  the  inner  canthus  and  giving 
the  appearance  of  a  very  broad  bridge  of  the  nose.  It  may 
be  accompanied  by  ptosis.  Treatment  consists  in  removing  a 
piece  of  skin  from  the  bridge  of  the  nose. 

Coloboma  of  the  lid  is  a  congenital  defect  of  rare  occur- 
rence. It  is  a  cleft  in  the  lid  similar  to  cleft-palate  and  hare- 
lip.    It  may  also  be  traumatic  origin. 


TUMORS    OF    THE   LID. 

Varieties. — Beside  chalazion  and  hordeolum  a  number  of 
benign  tumors  are  found  on  the  lid,  including  verruca  (wart), 
molluscum  contagiosum,  xanthelasma,  dermoid  cysts,  milia, 
vascular  tumors,  cutaneous  horns,  and  small  transparent  cysts 
at  the  edge  of  the  lids  (glands  of  Moll). 

Molluscum  contagiosum  appears  as  a  rounded  elevation 
formed  by  the  hypertrophy  of  a  sebaceous  gland  and  duct. 


48  DtSEAsm  OF  WE  LWS. 

On  top  will  be  found  a  pit  out  of  which  cheesy  material  may 
he  pressed.     They  sometimes  reach  a  considerable  size. 

Xanthelasma  is  a  chamois-skin-colored,  flat,  slightly  ele- 
vated tumor  of  connective  tissue  with  fatty  degeneration 
involving  the  whole  skin.  It  occurs  usually  on  the  upper  lid 
of  elderly  persons.  It  should  be  thoroughly  excised  and  the 
wound  closed  with  sutures. 

Vascular  Tumors. — Angiomata  in  the  form  of  nsevus  tel- 
angiectasia or  cavernoma  should  be  treated  by  electrolysis  or 
excised. 

Malignant  Tumors. — Sarcoma  is  rarely  seen. 

Carcinoma  in  the  form  of  rodent  ulcer  is  found  in  elderly 
individuals.  It  begins  as  a  small  elevation,  which  breaks 
down  into  an  ulcer,  perhaps  at  first  not  malignant.  The 
ulceration  increases  indefinitely,  sometimes  healing  in  places. 

Treatment. — Thorough  excision,  going  well  into  the  healthy 
tissue,  should  be  practised  unless  the  condition  has  advanced 
too  far.  It  is  often  necessary  to  replace  parts  of  the  lid 
which  are  thus  sacrificed  by  sliding  flaps  or  by  flaps  with 
pedicle  from  the  forehead,  cheek,  or  temple  (blepharoplasty). 
The  use  of  caustics  should  generally  be  avoided.  The  A^-ray, 
Fin  sen  light,  and  radium  promise  usefulness  in  certain  of  these 
cases. 

QUESTIONS. 

Name  the  principal  diseases  of  the  lids. 

Mention  the  varieties  and  treatment  of  blepharitis  marginalis. 
State  the  differential  diagnosis  between  hordeolum  and  chalazion.     Give 
the  treatment  for  each. 

What  are  the  causes  of  ectropion  and  entropion,  and  the  treatment  of  each  ? 

Define  and  state  the  causes  and  treatment  of  ptosis. 

Wliat  conditions  of  the  lids  are  due  to  traumatism  ? 

Mention  the  common  benign  and  malignant  tumors  of  the  lids. 

Describe  forms  of  blepharospasm. 

Define  lagophthalmos,  epicanthus,  and  coloboma. 

To  what  cutaneous  affections  may  the  lids  be  subject? 


DISEASES  OP  THE  COMtlNCTlVA,  40 

CHAPTER   IV. 

DISEASES  OF  THE   CONJUNCTIVA. 

CONJUNCTIVITIS    (OPHTHALMIA). 


Classification. 


Conjunctivitis 


Catarrhal    .    |  Au"^*'- 
I  Chronic. 

pi,         J  Ophthalmia  neonatorum, 

\  Gonorrhoeal  conjunctivitis. 

Granular.  .       Trachoma. 

Phlyctenular. 

Membranous  I  ^™"irV 
(  Diphtheritic. 

ACUTE    CATARRHAL    CONJUNCTIVITIS. 

Synonyms. — Acute  mucopurulent  conjunctivitis ;  Acute  con- 
tagious conjunctivitis ;  "  Pink-eye.'^ 

Definition. — An  acute  catarrhal  inflammation,  especially  of 
the  palpebral  conjunctiva,  characterized  by  congestion,  swell- 
ing, and  mucopurulent  discharge. 

Etiology: — Exposure  to  wind,  dust,  and  smoke,  or  presence 
of  irritating  foreign  substances.  Koch- Weeks  bacillus,  pneu- 
mococcus,  streptococcus,  staphylococcus,  and  Morax-Axenfeld 
diplobacillus  are  responsible  for  infection  in  different  cases. 
It  may  be  associated  with  the  exanthemata.  Occurs  in  epi- 
demic form,  especially  in  spring  and  fall. 

Varieties. — A  number  of  varieties  exist,  but  clinically  they 
may  be  classed  under  two  heads :  simple  and  infectious^  the 
latter  being  generally  due  to  the  Koch- Weeks  bacillus  and 
called  acute  epidemic  conjunctivitis. 

Subjective  Symptoms. — Patients  complain  of  stiffness  of  the 
lids,  photophobia,  epiphora,  burning,  and  sensations  of  a  for- 
eign body.  There  is  no  actual  pain,  but  considerable  discom- 
fort, especially  in  the  evening. 

Objective  Symptoms. — The  lids  are  swollen  and  red.     The 

4— E.  E. 


50  DISEASES  OF  THE  CONJUNCTIVA. 

conjunctiva  of  the  globe  is  more  or  less  deeply  congested,  and 
that  of  the  lid  is  thickened,  congested,  and  rough.  Occasionally 
there  are  subconjunctival  hemorrhages.  The  mucopurulent 
discharge  is  collected  at  the  roots  of  the  lashes  or  lies  on  the 
surface  of  the  conjunctiva.  The  lids  are  stuck  together  in  the 
morning.  The  vision  is  only  slightly  affected  by  the  mucous 
discharge  on  the  surface  of  the  cornea,  which  is  otherwise 
clear,  although  minute  ulcerations  of  the  cornea  are  occasion- 
ally seen. 

Diagnosis  is  easily  made  by  the  presence  of  mucopurulent 
discharge,  deep  congestion  involving  the  conjunctiva  (espe- 
cially palpebral),  clear  vision,  and  absence  of  pain.  Differen- 
tial diagnosis  will  be  found  under  the  head  of  acute  glau- 
coma. 

Course. — The  disease  usually  attacks  one  eye  a  few  days  in 
advance  of  the  other.  The  first  stage  of  congestion  lasts  a 
few  hours  or  a  day,  and  is  followed  by  the  stage  of  discharge, 
which  continues  a  few  days  to  a  week  or  more.  Most  cases 
recover  quickly,  but  the  greatest  danger  is  in  chronic  con- 
junctivitis and  blepharitis  remaining  as  sequelae. 

Prophylactic  Treatment. — As  epidemic  conjunctivitis  is  con- 
tagious, and  often  attacks  a  whole  family,  the  promiscuous  use 
of  towels,  etc.,  should  be  avoided. 

Active  Treatment. — In  the  first  stage  applications  of  gauze 
or  cotton  taken  directly  from  ice  are  indicated,  together  with 
a  wash,  such  as  boric  acid  solution  (3  per  cent.),  chlorine  water 
(50  per  cent.),  or  formaldehyde  (1  :  5000).  In  addition  to 
this,  when  the  discharge  appears,  astringents  are  called  for, 
such  as  applications  of  nitrate  of  silver  (1  per  cent.).  An 
efficient  prescription  is  as  follows  : 

1^     Zinci  sulphatis,  0.10; 

Alum,  0.15; 

Aqua?  destill.,  25.00. 

M.  Sig. — One  drop  into  eye  twice  or  three  times  a  day. 

The  lids  should  be  anointed  with  vaselin  at  night  to  pre- 
vent sticking  with  discharge.     The  common  practice  of  apply- 


CHMONIC  CATARRHAL  CONJUNCTIVITIS.  51 

ing  poultices  of  tea-leaves  or  bread  and  milk  is  to  be  con- 
demned, and  the  eyes  should  not  be  bandaged. 

CHRONIC    CATARRHAL   CONJUNCTIVITIS. 

Definition. — A  chronic  catarrhal  inflammation  usually  con- 
fined to  the  palpebral  conjunctiva. 

Etiology. — May  follow  an  acute  conjunctivitis.  It  is  caused 
by  dusty  atmosphere,  night  work,  and  late  hours ;  may  be  due 
to  eye-strain  from  errors  of  refraction  or  improper  use.  It 
may  be  associated  with  nasal  catarrh  or  with  constitutional 
disturbances,  such  as  rheumatism  and  gout. 

Subjective  Symptoms. — There  is  complaint  of  burning, 
smarting,  itching,  sensations  of  a  foreign  body,  blurring, 
lachrymation,  photophobia,  dryness,  heaviness,  sleepiness,  and 
discharge,  which  sticks  the  lids  together  in  the  morning. 

Objective  Symptoms. — The  palpebral  conjunctiva  varies  in 
appearance  from  slight  injection  to  deep  congestion,  and  the 
surface  may  be  studded  with  granulations  or  cheesy  deposits 
(lithiasis),  and  be  more  or  less  thickened.  The  edges  of  the 
lids  are  hypersemic,  and  there  is  watery  or  mucopurulent  dis- 
charge, with  excoriations  of  the  skin,  especially  at  the  outer 
and  inner  canthus.  Occasionally  a  white  flocculent  discharge 
will  be  found,  which  is  chemically  a  soap,  with  sodium  as  a 
base. 

Course. — The  disease,  which  is  extremely  common,  runs  a 
protracted  course,  being  subject  to  exacerbations  at  intervals. 
Both  eyes  are  usually  aflPected. 

Systemic  Treatment. — Unfavorable  conditions  should  be 
corrected. 

Local  measures  consist  in  the  use  of  astringents.  In  mikl 
cases  boric  acid  in  saturated  solution,  zinc  sulphate  (0.3  per 
cent.),  alum  (0.5  per  cent.),  tannic  acid  (1  per  cent.),  chlorate 
of  potassium  (0.3  per  cent.),  tine,  opii  (50  per  cent.),  or  pro- 
targol  (5  per  cent.),  may  be  tried.  In  marked  or  obstinate 
cases  applications  of  silver  nitrate  (1  to  2  per  cent.),  every 
day  or  every  other  day,  are  indicated.  Daily  application  of 
alum  crystal  is  an  excellent  remedy.     ^N^asal  catarrh  should 


62  PTSEASES  OF  THE  CONJUNCTIVA. 

be  treated.     The  disease  Is  often   intractable,  and    frequent 
changes  in  treatment  are  desirable. 

CHRONIC   FOLLICULAR   CONJUNCTIVITIS. 

Synonym. — Follicularis. 

Definition. — A  chronic  disease  of  the  palpebral  conjunctiva, 
characterized  by  the  presence  of  hypertrophied  follicles,  with 
few  or  no  inflammatory  signs. 

Etiology. — Common  in  youth,  especially  in  strumous  chil- 
dren who  live  under  unfavorable  hygienic  surroundings.  It 
may  be  infectious. 

Pathology. — The  "  follicles ''  are  masses  of  lymphoid  tissue 
resembling  true  trachoma  granules. 

Subjective  symptoms  are  those  of  mild,  chronic  catarrhal 
conjunctivitis. 

Objective  Symptoms. — The  granulations  appear  as  small, 
round,  pale  elevations,  confined  to  the  fornix  and  nasal  por- 
tion of  the  lower  lid,  and  to  the  conjunctiva  at  the  edge  and 
over  the  extremities  of  the  tarsal  cartilage  of  the  upper  lid. 

Diagnosis. — Follicular  conjunctivitis  is  difficult  at  times  to 
differentiate  from  trachoma,  and  is  regarded  by  some  as  be- 
longing to  the  same  category.     (See  Trachoma.) 

Treatment  is  the  same  as  for  simple  chronic  conjunctivitis. 

OPHTHALMIA   NEONATORUM. 

Synonyms. — Purulent  conjunctivitis  in  the  infant;  Acute 
blennorrhoea ;  Gonorrhceal  conjunctivitis  in  the  new-born. 

Definition. — A  severe  conjunctivitis  in  the  new-born,  usually 
due  to  the  gonococcus  of  Neisser  and  characterized  by  puru- 
lent discharge. 

Etiology. — While  mild  cases  of  conjunctivitis  in  the  new- 
born may  be  occasioned  by  less  virulent  forms  of  infection 
from  the  parturient  canal  or  from  outside  causes,  and  are 
generally  classed  under  this  head,  the  majority  of  the  severer 
cases  are  due  to  gonococcus  infection. 

Symptoms. — The  first  symptoms  are  swelling  and  redness, 


y 


OPHTHALMA  NEONATORUM.  53 

usually  of  both  eyes,  occurring  the  second  or  third  day  after 
birth.  Very  soon  the  discharge  begins  to  appear,  and  shortly 
becomes  creamy  pus,  which  runs  from  the  eye  when  the 
swollen  lids  are  parted.  As  the  disease  advances  the  con- 
junctiva of  the  lids  is  thickened,  red,  and  velvety,  and  that 
of  rhe  eyeball  is  oedematous. 

Complications. — If  the  pus  is  allowed  to  remain  in  the  con- 
junctival sac,  the  cornea  may  become  hazy  and  ulcers  appear. 
if  an  ulcer  perforates,  the  iris  is  likely  to  be  caught  in  the 
opening  and  in  the  resulting  scar  (adherent  leucoma).  The 
cornea,  weakened  by  inflammation,  may  later  bulge  and  pro- 
duce anterior  staphyloma.  Or,  the  whole  eye  may  become 
involved  in  an  inflammation  which  results  in  its  destruction. 

Course. — The  disease  lasts  from  two  to  six  weeks,  often 
leaving  chronic  conjunctivitis. 

Prognosis. — If  seen  before  corneal  ulcerations  set  in,  the 
vast  majority  of  these  cases  recover. 

Treatment. — Ophthalmia  neonatorum  is  a  prolific  cause  of 
blindness,  and  its  nature,  prevention,  and  treatment  should 
be  thoroughly  understood. 

Prophylaxis. — In  public  institutions  and  at  times  in  private 
practice  the  Crede  method  should  be  employed.  It  consists 
in  dropping  a  2  per  cent,  solution  of  nitrate  of  silver  into  the 
conjunctival  sac  of  the  infant  at  birth.  Salt  solution  should 
be  used  immediately  afterward.  Tlie  frequency  with  which 
an  active  catarrhal  conjunctivitis  foUow^s  the  use  of  2  per 
cent,  solutions  of  nitrate  of  silver  has  led  to  the  employment 
of  1  per  cent,  strength  in  the  hands  of  many  observers.  The 
prophylactic  value  is  equally  great  and  the  undesirable  secon- 
dary catarrh  of  the  conjunctiva  is  much  less  common  than 
with  the  original  CrMe  strength.  Such  practice  has  greatly 
reduced  the  percentage  of  ophthalmia  neonatorum  in  lying-in 
hospitals.  It  is  well  also  to  douche  the  vagina  and  cleanse 
the  eyes  of  the  new-born  with  a  mild  antiseptic  solution,  such 
as  boric  acid  (3  per  cent.). 

Active  Treatment. — When  the  disease  is  established,  ener- 
getic treatment  should  be  instituted.  The  lids  should  be 
gently  separated  and  the  discharge  flushed  out  with  distilled 


54  DISEASES  OF  THE  CONJUNCTIVA, 

water,  salt  and  water,  boric  acid  solution  (2  to  3  per  cent.), 
or  permanganate  of  potassium  (1  :  3000),  care  being  taken  not 
to  touch  the  cornea  with  the  cotton  or  dropper.  Cleansing 
must  be  done  at  least  every  hour,  day  and  night.  Squares 
of  folded  gauze  or  masses  of  absorbent  cotton  should  be  taken 
cold  from  a  block  of  ice  and  laid  over  the  eyes  and  constantly 
changed.  The  conjunctiva  should  be  brushed  with  a  2  per 
cent,  solution  of  nitrate  of  silver  and  neutralized  with  salt 
solution  once  every  day.  Protargol  or  argyrol  (5  to  25  per 
cent.)  may  be  substituted.  The  generous  use  of  vaselin  be- 
tween periods  of  cleansing  is  an  excellent  procedure.  In 
corneal  complications  atropine  (1  per  cent.)  may  be  necessary. 
Attentive  nursing  is  the  greatest  desideratum.  The  attend- 
ants should  be  warned  of  the  contagious  character  of  the  dis- 
ease for  their  own  protection. 

GONORRHCEAL   CONJUNCTIVITIS. 

Synonyms. — Blennorrhoea ;  Purulent  conjunctivitis  in  the 
adult. 

Definition. — A  severe  and  serious  purulent  inflammation  of 
the  conjunctiva  due  to  the  presence  of  the  gonococcus. 

Etiology. — The  gonococcus  of  Neisser.  It  is  not  difficult  to 
see  how  the  conjunctiva  may  be  infected  by  the  patient.  That 
the  disease  is  not  more  prevalent  must  be  due  to  the  normal 
resisting  power  of  the  healthy  conjunctiva.  A  separate  class 
of  cases  resembling  this  disease  is  a  purulent  conjunctivitis  in 
young  girls  with  vaginal  discharge  which  is  not  gonorrhoeal. 

Symptoms. — The  patient,  who  generally  has  a  gonorrhoeal 
urethritis,  presents  himself  with  great  swelling  and  tension  of 
the  eyelids,  more  or  less  purulent  discharge  escaping  between 
the  lids.  The  conjunctiva  is  swollen  and  thickened.  There 
is  little  pain  but  great  discomfort.  The  cornea  soon  shows 
infiltration,  and  ulcers  form.  These  perforate,  leading  to 
destruction  of  the  eye  or  at  best  deep  corneal  opacities. 

Course. — One  eye  is  usually  first  affected  and  the  other 
only  escapes  by  careful  protection.  The  disease  lasts  from 
two  to  six  weeks  and  leaves  a  chronic  conjunctivitis  with 


TRACHOMA.  55 

thickened  granular  and  congested  conjunctiva  (chronic  blen- 
norrhoea). 

Prognosis  is  decidedly  grave.  The  majority  of  the  well- 
established  cases  result  in  loss  of  or  in  serious  damage  to 
the  eye  involved. 

Prophylactic  Treatment. — Individuals  with  gonorrhoea  should 
exercise  the  greatest  care  to  prevent  infection  of  the  eyes.  The 
healthy  eye  must  be  covered  by  a  watch-glass  framed  with 
surgeon's  plaster  and  closely  applied  about  the  eye  (BuUer's 
shield). 

Active  treatment  of  the  disease  is  entirely  similar  to  that  of 
a  severe  case  of  ophthalmia  neonatorum. 

Metastatic  Gonorrhceal  Conjunctivitis. — Cases  of  gon- 
orrhoeal  urethritis  complicated  by  systemic  infection  mani- 
festing itself  as  arthritis  may  suffer  from  conjunctivitis  of 
metastatic  origin.  There  is  little  or  no  discharge,  but  small 
corneal  ulcers  sometimes  appear. 

TRACHOMA. 

Synonyms.  —  Granular  conjunctivitis;  Granulated  lids; 
Egyptian  ophthalmia. 

Definition. — A  moderately  contagious  disease  in  which  the 
palpebral  conjunctiva  is  occupied  by  new  tissue,  usually  in 
the  form  of  small  elevations,  which  after  a  prolonged  exist- 
ence pass  over  into  cicatrices. 

Etiology. — The  disease  belongs  to  the  lower  classes,  among 
whom  sanitary  conditions  are  poor  and  cleanliness  is  not 
strictly  observed.  It  is  not  unlikely  that  the  origin  of  the 
disease  is  a  microorganism,  but  its  existence  has  not  been 
established.  It  is  more  common  among  certain  races — e.  g., 
Jews  and  Irish. 

Pathology. — The  trachoma  granulations  are  composed  of 
lymph-corpuscles  with  scanty  connective-tissue  stroma  and 
incomplete  capsule.     They  are  imbedded  in  the  conjunctiva. 

Trachoma  is  commonly  classified  as  follows : 

I.  Papillary  trachoma,  in  which  the  conjunctiva  is  hyper^ 


66  DISEASES  OF  THE  CONJUNCTIVA. 

trophied  and  folded,  forming  granulations  (papillae)  especially 
over  the  tarsal  cartilages.  The  appearance  is  velvety  or 
coarsely  granular.  This  form  occurs  also  after  blennorrhoea 
and  from  other  causes.  It  is  not,  properly  speaking,  true 
trachoma. 

II.  Granular,  follicular,  or  true  trachoma,  appears  as  round, 
transparent  bodies  (granules,  trachoma  follicles),  especially  in 
the  fornices.  Each  granule  is  a  mass  of  lymph-corpuscles, 
without  true  capsule. 

III.  Mixed  form,  where  the  two  are  associated.  This  is 
the  most  common. 

Symptoms. — The  disease  is  divided  into  three  stages  ;  I. 
Onset.     II.  Full  development.     III.  Cicatrization. 

Fig.  13. 


Typical  granular  lid  and  beginning  cicatrization,  with  pannus.    (Berry.) 

I.  The  onset  may  be  acute^  subacute^  or  chronic. 

a.  Acute  Onset  (Acute  Trachoma). — An  uncommon  form,  in 
which  there  are  rapid  swelling,  redness,  and  irritation  of  the 
lids.  The  conjunctiva  is  much  thickened,  red,  and  granular 
(papillae),  and  there  is  considerable  mucopurulent  or  purulent 
discharge.  This  condition  resembles  severe  acute  conjunctivi- 
tis, or  even  gonorrhoeal  conjunctivitis. 

6.  Subacute  Onset. — The  conjunctiva  is  moderately  swollen, 
deeply  congested,  and  roughened.  As  the  swelling  disappears 
the  true  granules  are  seen. 


TRACHOMA.  67 

c.  Chronic  Onset  (Noninflammatory  Trachoma). — There  is 
little  or  no  discomfort.  The  lids  may  appear  slightly  swollen. 
On  everting  the  lower  lid  masses  of  granulations  roll  out  from 
the  fornix,  and  the  upper  lid  shows  a  tarsus  covered  with 
granulations,  and  the  retrotarsal  fold  will  be  found  filled  with 
traclioraatous  masses.     Congestion  is  usually  absent. 

II.  Stage  of  Full  Development. — The  disease  usually  as- 
sumes the  mixed  form  with  papillae  and  granules.  There  is 
considerable  irritation,  lachrymation,  photophobia,  and  slight 
mucopurulent  discharge.  The  tarsal  cartilages  are  covered 
with  coarse  and  fine  granulations,  and  the  fornices  are  filled 
with  trachoma  masses.  The  conjunctiva  is  moderately  con- 
gested and  thickened.  This  condition  may  exist  for  years 
with  exacerbations,  but  gradually  passes  over  into  the  cicatri- 
cial stage. 

III.  Stage  of  Cicatrization. — White  or  bluish  areas  or  lines 
(cicatrices)  begin  to  appear  among  the  granular  masses,  and 
by  degrees  the  conjunctiva  presents  a  shining  surface  streaked 
with  white  cicatricial  bands.  The  fornices  are  practically 
obliterated  in  extreme  cases,  and  the  conjunctiva  becomes 
dry  (xerosis).  During  the  periods  of  full  development  and 
tmnsition  complications  make  their  appearance. 

Palpebral  Complications. — The  inevitable  contraction  which 
follows  when  granulation-tissue  is  converted  into  cicatricial 
tissue  is  accompanied  by  disastrous  results  in  the  eye,  for  the 
shrinking  of  the  inner  surface  of  the  lids  bends  the  tarsal 
cartilage  and  rolls  the  margin  of  the  lid  inward  (entropion), 
and  the  lashes  sweep  over  the  cornea  (trichiasis). 

Corneal  Complications. — A  superficial  vascular  keratitis  (pan- 
nus)  appears  w^ith  ulcerations  and  infiltration,  especially  on  the 
upper  half  of  the  surface  of  the  cornea,  with  bloodvessels 
running  down  over  the  cornea  from  the  conjunctiva  above. 
Pan n  us  may  cover  the  whole  cornea  and  leave  dense  opacities 
seriously  affecting  the  vision.  Ulcers  may  be  deep  and  per- 
forate. 

Deeper  complications  may  appear  in  the  form  of  iritis, 
cyclitis,  and  even  panophthalmitis,  from  which  phthisis  bulbi 
results. 


58  DISEASES  OF  THE  CONJUNCTIVA. 

Course. — Trachoma  is  essentially  a  chronic  disease,  often 
beginning  in  youth  and  continuing  for  years. 
.  Differential  Diagnosis. — Chronic  follicular  conjunctivitis  and 
trachoma  sometimes  resemble  each  other.  The  former  occurs 
in  youth.  The  granulations  are  small,  round,  in  rows,  occur- 
ring especially  on  the  nasal  half  of  the  conjunctiva  of  the 
lower  lid  and  edge  and  extremities  of  the  cartilage  of  the 
upper  lid.  The  disease  is  amenable  to  treatment  and  the 
granulations  disappear  without  leaving  a  trace.  Trachoma, 
on  the  contrary,  is  a  progressive  disease,  lasting  for  many 
years.  The  granulations  are,  as  a  rule,  larger,  less  prominent, 
more  uniformly  distributed,  and  at  last  disappear,  leaving 
cicatrices. 

Prophylactic  Treatment. — Children  in  schools  and  asylums 
should  be  protected  against  this  common  contagious  disease. 
Individual  towels  and  handkerchiefs  should  be  provided,  and 
cleanliness  enforced.  Cases  should  be,  to  a  certain  extent, 
isolated. 

Medicinal  Treatment. — The  sovereign  remedy  is  sulphate 
of  copper.  The  crytals  should  be  rubbed  over  the  diseased 
portion  of  the  lids  every  day  or  every  other  day,  not  forgetting 
to  go  well  under  the  tarsal  cartilage  into  the  retrotarsal  fold 
of  the  upper  lid.  The  eyes  should  be  immediately  bathed 
with  cold  water.  Nitrate  of  silver  (1  per  cent,  solution)  is  a 
good  substitute  for  short  periods.  If  applied  too  long,  it  will 
cause  permanent  staining  of  the  conjunctiva  (argyrosis,  argy- 
ria).  Tannin  and  glycerin  (60  grains  to  the  ounce)  is  of 
slight  value.  Also,  mercuric  chloride  (1  :  1000)  may  be  used. 
Applications  of  yellow  oxide  of  mercury  ointment  (1  per 
cent,  for  home  treatment)  are  useful  in  later  stages.  Atropine 
may  be  necessary  in  corneal  and  iridic  complications. 

Surgical  treatment  consists  in  mechanically  crushing  the 
granulations.  The  roller-forceps  of  Knapp  is  generally  used 
for  this  purpose.  The  granulations  are  caught  between  two 
grooved  rollers  and  their  contents  squeezed  out,  as  in  a 
wringer.  The  operation  should  be  thoroughly  performed 
under  a  general  anaesthetic.  The  lids  should  be  treated  with 
applications  of  copper  sulphate  for  some  time  after  the  expres- 


PHLYCTENULAR  CONJUNCTIVITIS.  59 

sion.  The  operation  is  indicated  in  noninflammatory  trachoma 
and  in  many  cases  with  well-marked  granulations.  Other  for- 
ceps sometimes  employed  are  those  of  Noyes  and  Prince. 

Grattage  is  a  method  in  which  the  granulations  are  broken 
by  rnbbing  with  a  stiff  tooth-brush.  It  should  be  used  with 
care. 

PHLYCTENULAR   CONJUNCTIVITIS. 

Synonyms. — Scrofulous  ophthalmia  ;  Eczematous  conjuncti- 
vitis. 

Definition. — A  disease  characterized  by  the  development  of 
small  papules  or  pustules  on  the  bulbar  conjunctiva. 

Etiology. — The  disease  occurs  in  strumous  children  and  in 
those  w^ho  are  ill-fed.  It  is  allied  to  eczema  in  its  nature  and 
often  is  associated  with  it  on  the  face.  It  is  rarely  seen  in  the 
adult.  It  is  commonly  accompanied  by  nasal  catarrh.  The 
same  lesions  occur  on  the  cornea  (phlyctenular  keratitis).  It 
is  probably  due  to  a  micro5rganism. 

Subjective  Symptoms. — The  child  complains  very  little  if 
the  phlyctenules  are  not  near  the  cornea.  There  is  some  pho- 
tophobia, irritation,  and  lachrymation. 

Objective  Symptoms. — On  the  bulbar  conjunctiva  will  be 
found  one  or  more  elevations  in  the  form  of  papules  or  pus- 
tules surrounded  by  a  circumscribed  area  of  congestion.  Later 
the  pustules  may  break  down  and  form  ulcers.  A  favorite 
site  is  at  the  margin  of  the  cornea.  It  is  then  clinically 
known  as  phlyctenula  marginalis.  Phlyctenules  often  form 
in  rapid  succession,  each  lasting  a  week  or  more.  Relapses 
are  common. 

General  Treatment. — Since  this  disease  is  a  manifestation 
of  constitutional  derangement,  tonics  such  as  iron,  quinine, 
and  cod-liver  oil  are  indicated.  Proper  food,  exercise,  and 
fresh  air  are  prescribed. 

Local  Treatment. — Once  or  twice  a  day  a  small  quantity  of 
yellow  oxide  of  mercury  ointment  (1  per  cent,  in  vaselin) 
should  be  placed  inside  the  lids  and  thoroughly  rubbed  about 
w^ith  the  lids  closed.     Atropine  (0.5  per  cent,  solution)  should 


60  DISEASES  OF  THE  CONJUNCTIVA, 

be  ordered  if  the  cornea  is  affected.     Calomel  may  be  dusted 
into  the  eye.     The  nose  should  receive  appropriate  treatment. 


MEMBRANOUS  CONJUNCTIVITIS. 

Membranous  conjunctivitis  is  a  rare  disease. 

Two  forms  are  described  under  the  heads  of  croupous  and 
diphtheritic. 

Croupous  conjunctivitis  is  the  more  common  variety,  and 
may  occur  as  a  complication  in  severe  forms  of  conjunctivitis 
in  children,  complicating  infectious  diseases,  or  as  the  result 
of  superficial  burns.  It  presents  a  membranous  deposit  which 
if  removed  leaves  a  bleeding  surface. 

Treatment  is  same  as  for  gonorrhoea!  conjunctivitis. 

Diphtheritic  conjunctivitis  is  a  rare  affection  due  to  the 
Klebs-Loeffler  bacillus.  The  reaction  may  be  comparatively 
slight  but  usually  the  lids  are  greatly  swollen,  reddened, 
tense,  and  stiff.  A  dirty  yellow  diphtheritic  membrane  is 
found  on  the  conjunctiva  when  it  is  possible  to  evert  the 
lids.  Constitutional  symptoms  of  diphtheria  are  present. 
The  necrosis  following  the  infiltration  of  the  conjunctiva 
results  in  a  granulating  surface  which  cicatrizes  and  deforms 
the  lid.     The  cornea  and  whole  eye  are  likely  to  suffer. 

Treatment. — Cases  should  be  isolated  and  the  other  eye  pro- 
tected. Diphtheritic  antitoxin  should  be  employed.  Locally 
the  treatment  is  the  same  as  for  gonorrhoeal  conjunctivitis. 


INJURIES  OF  THE  CONJUNCTIVA. 

Foreign  bodies  frequently  lodge  on  the  palpebral  con- 
junctiva. Wounds  and  burns  with  lime,  acids,  or  metals 
occur.  The  contraction  which  follows  extensive  destruction 
of  the  conjunctiva,  or  the  uniting  of  adjacent  surfaces  of  the 
conjunctiva  of  the  eyeball  and  lid,  produces  adhesions  which 
are  known  as  symblepharon.  It  may  be  partial  at  the  fornix 
or  in  the  form  of  bands,  leaving  the  fornix  free,  or  it  may 
completely  unite  the  lid  to  the  eyeball. 


MISCELLANEOUS  DISEASES  OF  THE  CONJUNCTIVA.      61 

Treatment. — If  symblepharon  is  simply  cut  and  the  lid 
freed  from  the  globe,  it  is  impossible  to  prevent  recurrence. 
Sliding  flaps  of  healthy  conjunctiva  should  be  made  to  cover 
the  cut  surfaces  and  prevent  reattachment.  Flaps  of  skin  or 
mucous  membrane  without  a  pedicle  are  rarely  successful. 
The  most  favorable  cases  are  the  bands  which  allow  a  probe 
to  be  passed  around  through  the  fornix. 


MISCELLANEOUS   DISEASES    OP    THE    CONJUNCTIVA. 

Spring  Catarrh. —  Synonyms. —  Vernal  catarrh;  Spring 
catarrh ;  Saemisch  spring  catarrh  ;  Conjunctivitis  sestiva. 

Definition. — A  peculiar,  uncommon  disease  characterized  by 
the  presence  of  nodular  masses  about  the  periphery  of  the 
cornea  and  extending  a  little  on  to  it,  associated  with  hard, 
flat,  pale  granulations  on  the  conjunctiva  of  the  upper  lid. 

Etiology  is  unknown. 

Symptoms. — The  disease  appears  either  with  circumcorneal 
lesion  or  granulations  on  the  lid  alone  or  both  together.  It 
usually  occasions  very  little  discomfort  except  some  irritation, 
photophobia,  and  sensation  of  a  foreign  body.  It  occurs  in 
the  spring,  summer,  and  autumn,  but  nearly  or  entirely  disap- 
pears in  the  winter.  As  the  corneal  lesions  are  all  confined 
to  the  periphery  they  do  not  affect  the  vision,  and  after 
recovery  usually  no  traces  are  left. 

Treatment  is  unsatisfactory  except  in  relieving  irritation. 

Xerosis  is  a  term  applied  to  two  different  affections.  The 
name  is  used  to  designate :  I.  The  condition  of  dryness  seen  in 
advanced  cicatricial  contraction  of  the  conjunctiva  such  as 
occurs  after  the  ravages  of  trachoma  (atrophy  of  the  conjunc- 
tiva, parenchymatous  xerosis). 

Treatment  of  this  condition  is  of  no  avail. 

The  term  also  applies  to :  II.  A  disease  which  shows  white 
plaques  on  the  surface  of  the  bulbar  conjunctiva  (epithelial 
xerosis),  due  probably  to  the  presence  of  xerosis  bacillus. 
This  membranous,  greasy  appearing  deposit  may  be  scraped 
off.     In  infants  (infantile  xerosis)  it  is  associated  with  maras- 


62  DISEASES  OF  THE  CONJUNCTIVA. 

mils  and  usually  complicated  by  indolent  ulcers  of  the  cornea. 
These  latter  cases  always  end  fatally. 

Treatment  in  adults  consists  in  scraping  off  the  membrane 
and  applying  antiseptics,  such  as  mercuric  chloride  (1  :  1000). 

Pterygium.  —  Definition.  —  A  superficial  membranous 
growth  having  its  base  near  the  inner  or  outer  canthus  and 
extending  with  its  point  toward  the  centre  of  the  cornea. 

Etiology. — This  growth  is  formed  of  hypertrophied  con- 
junctival tissue  and  thought  in  some  cases  to  be  an  extension 
of  the  Pinguecula  (page  63). 

Symptoms. — The  patient  complains  very  little  except  when 
the  pterygium  is  well  advanced  toward  the  centre  of  the 
cornea  and  astigmatism   is  produced  or  the  vision  cut  off. 


"^^^^^]^V^-^"^ 


Pterygium.    (Fnchs.) 


The  wing-like  membrane  occurs  most  often  on  the  nasal  side, 
may  be  on  the  temporal,  but  is  very  rare  above  or  below. 
When  progressive,  it  is  thick  and  somewhat  congested. 
When  nonprogressive,  it  is  dry,  thin,  and  nonvascular. 
Pseudopterygium  is  somewhat  similar  in  appearance,  but 
produced  by  burns  or  ulcers. 

Course. — It    extends  over   many   years   and  may  sponta- 
neously cease  advancing  at  any  time. 


MISCELLANEOUS  DISEASES  OE  THE  CONJUNCTIVA,  63 

Treatment. — Surgical  treatment  is  necessary.  If  the  pte- 
rygium is  dissected  off  the  cornea,  which  may  readily  be  done, 
and  then  cut  off,  it  will  recur.  It  is  necessary  to  cover  the 
loss  of  tissue  on  the  conjunctival  surface  with  a  conjunctival 
flap  which  will  extend  to  the  edge  of  the  cornea.  An  effec- 
tive method  (transplantation)  consists  in  dissecting  off  the 
pterygium  from  the  cornea  and  sclera,  leaving  the  base 
attached  and  burying  its  apex  beneath  the  undermined  con- 
junctiva below. 

Pinguecula  is  a  small  yellow  elevation  in  the  ocular  con- 
junctiva usually  on  the  nasal  side  and  near  to  the  cornea. 
It  is  a  hyaline  degeneration  of  the  conjunctiv^a  and  is  of 
common  occurrence  in  middle  and  late  life.  Occasionally  it 
becomes  inflamed.     No  treatment  is  required. 

Tuberculosis  of  the  conjunctiva  is  uncommon.  Primary 
lesions  have  been  recorded.  Secondary  affections  in  the 
form  of  nodules  or  ulcerations  occur  and  are  occasionally  asso- 
ciated with  nasal  disease. 

Parinaud's  disease  somewhat  resembles  tuberculosis  of  the 
conjunctiva.  It  is  accompanied  by  enlargement  of  the  pre- 
auricular and  cervical  glands  with  constitutional  symptoms. 
It  is  a  rare  disease. 

Syphilis  of  the  Conjunctiva. — Chancre  and  Gumma  are 
of  rare  occurrence. 

Amyloid  conjunctivitis  is  characterized  by  waxy  masses 
in  the  fornix. 

Ecchymosis  of  the  conjunctiva  is  extravasation  of  blood 
beneath  the  conjunctiva  due  to  rupture  of  bloodvessels. 
Caused  by  traumatism,  paroxysms  of  coughing,  as  in  whoop- 
ing-cough, and  spontaneously  in  elderly  persons  wdiose  blood- 
vessels are  sclerosed.     No  treatment  is  necessary. 

L3rmphangiectasis  of  the  Conjunctiva.  —  Clusters  of 
transparent  blisters  in  the  bulbar  conjunctiva  due  to  dilata- 
tion of  lymph-spaces. 

Chembsis  of  the  Conjunctiva. — (Edema  of  the  bulbar 
conjunctiva  occurring  in  violent  inflammatory  conditions  of 
the  eye. 

Pemphigus  of  the  Conjunctiva. — Bullae  form,  and  are 


64  DISEASES  OF  THE  CORNEA, 

followed  by  cicatricial  tissue  which  destroys  the  whole  con- 
junctiva. "Essential  shrinking"  of  the  conjunctiva  is  an 
allied  process.     The  conditions  are  extremely  rare. 

Tumors  of  the  Conjunctiva. — Cyst,  angioma,  dermoid, 
lipoma,  fibroma,  papilloma,  epithelioma,  and  sarcoma  have 
been  described. 

QUESTIONS. 

Give  the  classification  of  conjunctivitis. 

Give  the  differential  diagnosis  between  acute  conjunctivitis,  iritis,  and 
glaucoma. 

Describe  the  treatment  of  acute  catarrhal  conjunctivitis. 

Describe  chronic  catarrhal  and  chronic  follicular  conjunctivitis. 

Give  definition,  etiology,  symptoms,  complications,  and  treatment  of  oph- 
thalmia neonatorum. 

Describe  gonorrhceal  conjunctivitis. 

What  are  the  varieties  of  trachoma  ?  Give  the  pathology,  the  stages,  the 
complications,  and  differential  diagnosis  between  trachoma  and  follicular  con- 
junctivitis? 

What  two  forms  of  membranous  conjunctivitis  occur? 

Define  spring  catarrh,  xerosis,  pterygium,  symblepharon,  and  Pinguecula. 

Mention  other  rarer  diseases  of  the  conjunctiva. 

What  microorganisms  cause  diseases  of  the  conjunctiva? 

What  is  the  prognosis  for  the  various  diseases  of  the  conjunctiva? 


CHAPTER  V. 
DISEASES  OF  THE  CORNEA. 

ULCER   OF    THE   CORNEA. 

Definition. — Superficial  loss  of  substance  accompanied  by 
more  or  less  infiltration  of  adjacent  cornea. 

Etiology.— Depression  in  the  general  health  is  an  under- 
lying cause,  or  there  may  be  poor  nutrition  of  the  cornea 
itself.  Ulcers  are  more  common  among  the  poorer  classes. 
Thev  often  begin  in  an  abrasion  produced  by  a  foreign  body. 
May  be  associated  with  diseases  of  the  conjunctiva  or  lachrymal 
apparatus. 

Pathology. — The  process  is  a  necrosis  of  the  superficial 
layers  of  the  cornea  due  to  infection.  Among  the  micro- 
organisms which  have  been  found  are  staphylococcus,  strepto- 


VLCER  OF  THE  CORNEA.  65 

coccus,  pneumococcus,  Morax-Axenfeld  bacillus,  gonococcus, 
and  aspergillus. 

Varieties. — A  broad  distinction  may  be  made  between 
simple  or  nonprogressive  ulcers  and  infected  or  progressive 
ulcers.  Simple  ulcers  are  small,  may  follow  abrasions  with 
clean  foreign  bodies,  are  amenable  to  treatment  and  not  asso- 
ciated with  deep-seated  complications.  They  are  due  to  some 
mild  form  of  infection.  Infected  ulcers,  on  the  contrary, 
may  follow  injuries  with  dirty  foreign  bodies,  often  resist  all 
treatment,  tend  to  spread,  and  are  accompanied  by  complica- 
tions. They  are  due  to  some  active  form  of  infection — e.  g., 
pneumococcus. 

The  important  clinical  varieties  are  : 

Phlyctenular  ulcer  (see  Phlyctenular  Keratitis). 

Traumatic  idcer.     Following  abrasions  or  wounds. 

Serpent  ulcer  (Saemisch  ulcer).  An  infected  ulcer  with 
advancing  crescent-shaped  edge. 

Dendritic  ulcer.  An  infected  ulcer  branching  in  shape,  and 
superficial.     May  be  malarial  in  origin. 

Ring  ulcer.  Attacking  the  periphery  of  the  cornea  and 
sometimes  completely  encircling  it. 

Indolent  ulcer  (absorption  ulcer).  Shows  little  or  no  inflam- 
matory signs.  Occurs  in  the  aged,  in  marasmic  infants,  and 
in  debilitated  subjects. 

Catarrhal  ulcer.     Accompanying  catarrhal  conjunctivitis. 

Subjective  Symptoms. — The  patient  complains  of  photo- 
phobia, lachrymation,  sensations  of  foreign  body,  more  or  less 
pain  especially  in  infected  ulcers.  There  is  defect  in  vision 
w^hen  the  ulcer  is  over  the  pupil. 

Objective  Symptoms. — The  eyeball  shows  a  ring  of  pink 
congestion  about  the  cornea  (circumcorneal),  together  with 
more  or  less  congestion  of  the  conjunctiva.  Ulcers  vary 
greatly  in  appearance,  but  in  general  with  oblique  illumina- 
tion show  a  superficial  loss  of  substance  in  the  cornea  with  a 
gray  opacity  (leucocyte  infiltration)  in  the  adjacent  tissue. 
The  form  of  the  ulcer  may  be  irregular,  circular,  crescentic, 
dendritic  (branching),  or  punctate. 

Course. — Simple  ulcers  usually  heal  kindly  in  a  week  or 

5— E.  E. 


66  DISEASES  OF  THE  CORNEA. 

two  by  throwing  off  the  necrotic  tissue  and  replacing  it  with 
connective  tissue.  Infected  ulcers  may  progress  by  spread- 
ing superficially,  by  undermining  healthy  tissue  with  an  ad- 
vancing edge   or  in   branching   lines.     Or,   they  may   sink 


Fia.  15. 

'        *' 

fl 

fek 

H^ 

K> 

Corneal  ulcer.    (Sichel.) 


deeply  into  the  substance  of  the  cornea  and  even  perforate. 
Sometimes  the  progress  is  by  colonies,  which  break  out  in  all 
directions.    When  the  healing  process  has  begun,  bloodvessels 


Fig.  16. 


Hypopyon,  seen  from  the  front,  and  in  section,  to  show  that  the  pus  is  behind 
the  cornea.    (Nettleship.) 

will  often  be  found  running  inward  from  the  periphery  of  the 
cornea. 

Complications. — Opacities  of  the  cornea  are  the  inevitable 
result  of  filling  of  the  ulcer  with  connective  tissue.  The 
effect  on  the  vision  depends  on  their  density  and  situation. 


ULCEB  OF  THE  CORNEA.  67 

If  a  deep  ulcer  perforates  into  the  anterior  chamber,  there  is 
danger  of  the  iris  being  caught  in  the  resulting  scar,  in  which 
case  the  condition  is  called  adherent  leucoma.  The  cornea 
weakened  by  ulceration  may  later  bulge,  forming  staphyloma, 
which  may  or  may  not  contain  the  prolapsed  iris. 

In  infected  ulcer  a  quantity  of  pus  is  sometimes  seen  in  the 
lower  part  of  the  anterior  chamber  (hypopyon).  This  is  com- 
posed of  cells  thrown  off  from  the  iris  and  endothelial  layer 
of  the  cornea  as  the  result  of  irritation.  At  times,  also,  pus 
will  accumulate  on  the  substance  of  the  cornea  (formerly 
called  onyx),  which  may  break  down  into  an  abscess.  Iritis 
is  a  common  complication  of  infected  ulcers.  Iridocyclitis 
and  even  panophthalmitis  may  follow,  with  destruction  and 
shrinking  of  the  eye  (phthisis  bulbi). 

Diagnosis. — The  presence  and  extent  of  the  loss  of  substance 
may  be  visibly  demonstrated  by  the  use  of  a  drop  of  2  per 
cent,  solution  of  fluorescin,  which  stains  the  exposed  area  a 
bright  green.  An  ulcer  may  be  known  from  an  old  opacity 
by  the  presence  of  circumcorneal  congestion,  subjective  symp- 
toms, loss  of  substance,  or  roughened  surface  of  the  cornea. 

Preventive  Treatment.— After  abrasions  of  the  cornea  a  mild 
antiseptic  should  be  given  in  the  form  of  eye-drops — boric 
acid,  saturated  solution,  or  mercuric  chloride  (1  :  5000).  In 
removing  a  foreign  body  aseptic  instruments  should  be  em- 
ployed. Complicating  conjunctivitis  or  dacryocystitis  should 
be  treated. 

Constitutional  Treatment. — It  is  important  to  treat  the  gen- 
eral condition  if  infected  ulcers  are  associated  with  debility, 
syphilis,  or  improper  mode  of  life. 

Local  Treatment. — Atropine  (1  to  2  per  cent.)  should  be 
instilled  three  to  six  times  a  day.  Eserine  is  sometimes  of 
use,  but  tends  to  produce  iritis.  Hot  fomentations,  re- 
peated according  to  the  severity  of  the  case,  and  an  anti- 
septic should  be  prescribed,  such  as  boric  acid  (3  per  cent.), 
permanganate  of  potassium  (1  :  3000),  or  chlorine  water  (50 
per  cent).  Indolent,  phlyctenular,  and  healing  ulcers  should 
be  stimulated  by  rubbing  in  the  eye  yellow  oxide  of  mercury 
ointment  (1  per  cent,  in  vaselin).     Calomel  or  iodoform  may 


68  DISEASES  OF  THE  GOttNEA. 

also  be  dusted  into  the  eye.  If  there  is  much  irritation,  holo- 
caine  (1  per  cent.)  may  be  instilled.  A  pressure-bandage  is 
indicated  unless  there  is  much  conjunctival  discharge.  In 
infected  ulcers  more  energetic  treatment  is  required  to  arrest 
the  infection.  In  addition  to  the  above  the  base  and  edges 
should  be  scraped  with  the  eye  under  cocaine  (5  per  cent.), 
and  nitrate  of  silver  (1  per  cent.)  or  tincture  of  iodine  (full 
strength)  should  be  applied  by  means  of  cotton  on  an  appli- 
cator once  a  day  or  once  every  other  day.  The  actual  cautery, 
such  as  a  red-hot  strabismus- hook  or  electrocautery,  may  be 
tried.  The  application  should  be  in  tlie  form  of  numerous 
punctures  at  the  edge  of  the  ulcer.  If  hypopyon  is  present, 
it  is  sometimes  wise  to  split  the  ulcer  into  the  anterior  chamber 
with  a  knife  (Saemisch  operation).  Dense  opacities  left  after 
ulcerations  are  sometimes  conspicuous,  and  may  be  tattooed 
by  the  introduction  of  India  ink  with  needle-pricks.  An 
artificial  pupil  may  sometimes  be  made  through  the  iris  if 
the  pupil  is  covered  by  the  opacity. 

INTERSTITIAL  KERATITIS. 

Synonym. — Diffuse  parenchymatous  keratitis. 

Definition. — A  chronic  inflammation  involving  the  paren- 
chyma of  the  cornea,  characterized  by  deep-seated  opacities 
and  circumcorneal  congestion. 

Etiology. — The  common  form  of  this  disease  a])pears  in 
children  and  is  due  to  congenital  syphilis.  It  rarely  occurs 
in  acquired  syphilis.  It  has  been  known  to  occur  in  utero. 
The  disease  may  also  be  due  to  malaria,  rheumatism,  gout, 
tuberculosis,  and  rickets,  or  may  be  idiopathic. 

Pathology. — The  cornea  normally  has  no  bloodvessels,  and 
inflammatory  action  consists  in  infiltration  of  leucocytes,  al- 
though occasionally  in  this  disease  a  deep-seated  vasculariza- 
tion may  take  place  at  the  periphery. 

Subjective  Symptoms. — The  patients  complain  of  moderate 
pain,  photophobia,  and  poor  vision. 

Constitutional  Objective  Symptoms. — Congenital  syphilis  is 
usually  easily  recognized  in  other  parts  of  the  body  by  char- 


INTERSTITIAL  KERATITIS.  69 

acteristic  signs,  such  as  the  so-called  Hutchinson  teeth.  The 
incisors  of  the  permanent  set  are  small,  furrowed  from  side  to 
side,  peg-shaped,  narrowed,  and  notched  at  the  extremity. 
The  face,  especially  at  the  angles  of  the  mouth  and  forehead, 
is  scarred  and  wrinkled  from  early,  even  intra-uterine,  ulcer- 
ations. The  head  is  large  and  square.  The  lymph-glands 
are  enlarged.  The  bridge  of  the  nose  is  flat,  and  there  are 
chronic  aural  and  nasal  troubles. 

Local  Objective  Symptoms, — The  opacities  of  the  cornea  may 
begin  at  any  point,  but  usually  at  the  periphery  as  a  thin,  gray 
cloud.  The  opacities  spread  and  often  completely  cover  the 
cornea,  becoming  at  times  a  dense  white  or  yellowish  and 
mottled.  Deep-seated  bloodvessels  will  enter  from  the  sclera 
and  produce  a  dense  red  spot  called  "  salmon  patch.''  The 
surface  of  the  cornea  is  sometimes  dull  and  rough  and 
"  steamy."  There  is  little  or  no  tendency  to  ulceration, 
although  it  is  possible  for  the  cornea  to  weaken  and  bulge, 
forming  staphyloma. 

Course. — Both  eyes  are  usually  affected,  although  it  may  be 
at  different  times.  The  disease  occurs  between  the  ages  of 
five  and  fifteen,  though  sometimes  seen  as  late  as  thirty  years. 
It  is  slow  in  its  course,  lasting  from  two  months  to  a  year  or 
more.  The  opacities  clear  often  to  a  remarkable  degree,  but 
in  severe  cases  the  vision  is  more  or  less  impaired.  Relapses 
are  common.  Complications  in  the  form  of  inflammations  of 
the  uveal  tract  (iritis,  cyclitis,  and  choroiditis)  often  occur  in 
severe  cases. 

Internal  Treatment. — Mercury  and  iodide  of  potassium,  in 
doses  suited  to  the  age  of  the  patient,  are  indicated,  although 
the  cases  of  congenital  syphilis  may  do  as  w^ell  with  tonics,  such 
as  iron  and  cod-liver  oil,  with  out-of-door  life. 

Local  Treatment. — Atropine  (1  per  cent.)  should  be  instilled 
three  times  a  day  during  the  active  period,  and  hot  fomenta- 
tions applied  regularly  for  at  least  fifteen  minutes  four  times 
a  day.  Stimulation  by  rubbing  in  the  yellow  oxide  of  mer- 
cury ointment  is  of  value,  if  there  is  not  too  much  irritation. 
Dark  glasses  should  be  worn.  Injections  of  normal  salt  solu- 
tion under  the  ocular  conjunctiva  (subconjunctival  injections) 


70  DISEASES  OF  THE  CORNEA. 

may  be  tried.     In  acquired   syphilis  energetic  antisyphilitic 
treatment  is  necessary. 

PHLYCTENULAR  KERATITIS. 

Definition. — The  disease  is  of  the  same  nature  and  due  to 
the  same  causes  as  phlyctenular  conjunctivitis. 

Varieties. — a.  Fascicular  keratitis.  An  ulceration  whicli 
presents  a  curved,  advancing  edge  of  infiltration  with  a  bunch 
of  bloodvessels  passing  to  it  from  the  corneal  edge.  This 
often  continues  across  the  cornea  and  leaves  a  row  of  perma- 
nent opacities,  b.  Multiple  ulcers,  with  more  or  less  super- 
ficial vascularization. 

Symptoms. — The  young  patient  suffers  greatly  from  photo- 
phobia and  buries  the  head  in  the  pillow.  There  is  tonic 
blepharospasm,  and  the  lids  are  separated  with  difficulty. 

Treatment. — Atropine  (1  per  cent.)  t.  i.  d.  Yellow  oxide 
of  mercury  ointment  (1  per  cent.)  rubbed  in  at  night.  If 
there  is  great  blepharospasm,  the  face  may  be  plunged  into 
a  basin  of  cold  water.  Constitutional  treatment  is  the  same 
as  for  phlyctenular  conjunctivitis. 

STAPHYLOMA. 

Synonym. — Ectasia. 

Definition. — A  bulging  of  the  cornea  or  sclera,  not  due  to 
swelling  or  thickening  of  the  tissues.  Staphyloma  occurs  in 
cornese  which  have  been  the  subject  of  disease  which  has 
weakened  their  resisting  power  to  internal  pressure,  such  as 
ulcerations,  abscesses,  or  injuries.  It  is  called  partial  or  total 
staphyloma  depending  upon  the  extent  of  the  cornea  involved. 
When  total  and  very  prominent,  the  lids  can  not  close.  The 
eye  is  usually  blind  from  previous  inflammation,  and  some- 
times the  eyeball  itself  is  shrunken. 

Treatment. — For  total  staphyloma,  operation  consists  in 
abscission  of  the  protrusion  and  suturing  the  edges  together ; 
this  is  done  for  cosmetic  reasons.  The  operation  is  usually 
safe,  although  serious  inflammation  has  been  known  to  follow. 


KERATOCONUS. 


71 


KERATOCONUS. 

Synonym. — Conical  cornea. 

Definition. — A  peculiar  disease  consisting  in  gradual  bulg- 
ing of  the  transparent  cornea  into  a  conical  form  with  the 
apex  at  or  near  the  centre.  The  process  may  begin  at  any 
period  of  life,  but  usually  in  youth,  progresses  slowly  for 
many  years  without  signs  of  inflammation,  and  may  become 
stationary  at  any  time. 

Symptoms. — The  patients  complain  of  increasing  defect  in 
vision.  On  examination,  in  marked  cases  the  conical  form 
of  the  cornea  is  very  evident,  especially  when  viewed  from 
the  side.     In  slight  cases  a  reflex  from  the  window  is  greatly 

Fk;.  17. 


Conical  cornea.     (Dalrymple.) 


distorted  by  lengthening  on  every  side  from  the  apex  of  the 
protrusion.  The  change  in  the  curve  of  the  cornea  creates  a 
high  degree  of  astigmatism  and  myopia.  A  gray  opacity  may 
appear  at  the  apex  of  the  cone  and  ulcerate. 

Treatment. — The  progressive  character  of  the  condition 
must  be  established  by  extended  observation.  If  nonpro- 
gressive, strong  cylinders  often  greatly  improve  the  vision  and 
should  be  carefully  selected.  If  progressive,  treatment  should 
begin  at  once,  and  consists  in  destroying  a  portion  of  the 
cornea  at  the  apex  of  the  cone  in  the  hope  that  the  contraction 


72  DISEASES  OF  THE  CORNEA. 

following  will  flatten  the  protrusion.  The  best  method  is  to 
burn  deeply  with  the  electric  cautery,  using  a  small  electrode 
with  a  flattened  end. 

INJURIES  OF  THE  CORNEA. 

Abrasions. — The  anterior  epithelial  layers  of  the  cornea  are 
easily  torn  off  by  a  foreign  body.  If  the  object  is  clean,  the 
cells  will  reform  in  a  few  hours  under  a  bandage.  If  ih^ 
abrasion  is  infected  by  the  foreign  body  or  by  bacteria  already 
in  the  conjunctival  sac,  an  ulcer  will  result,  which  may  lead 
to  disastrous  consequences.  The  pain,  photophobia,  and  lach- 
rymation  are  quite  intense  after  an  abrasion,  owing  to  exposure 
of  the  nerves. 

Treatment. — An  antiseptic,  such  as  mercuric  chloride 
(1  :  5000)  or  boric  acid  (saturated  solution),  should  be  pre- 
scribed and  the  eye  bandaged. 

Burns  of  the  cornea  may  be  by  hot  w^ater,  steam,  metals, 
acids,  and  alkalies.  If  superficial,  being  aseptic,  they  heal 
quickly ;  if  deep,  the  scars  may  affect  the  vision. 

Treatment. — Atropine  (1  per  cent.)  and  a  bandage  are  indi- 
cated. 

FOREIGN  BODIES. 

The  cornea,  on  account  of  its  soft  structure  and  its  exposed 
position,  is  a  favorite  lodging-place  for  foreign  bodies,  such 
as  particles  of  dust,  cinders,  coal,  emery,  and  steel.  For  the 
detection  of  a  foreign  body  it  is  necessary  to  use  the  oblique 
illumination  and  sometimes  a  magnifying-glass  in  addition. 

Treatment. — The  eye  should  be  thoroughly  anaesthetized  by 
dropping  in  a  solution  of  cocaine  (4  per  cent.)  or  holocaine 
(1  per  cent.)  twice  with  ten  minutes'  interval.  The  eyelids 
should  be  spread  apart  with  the  fingers  or  with  a  speculum, 
and  the  foreign  substance  picked  out  of  the  cornea  by  the  use 
of  a  sterilized  blunt  spud  or  foreign-body  needle.  Great  care 
must  be  exercised  not  to  injure  the  cornea  more  than  is  abso- 
lutely necessary.  Some  foreign  bodies,  especially  emery  and 
bits  of  steel,  may  be  quite  deeply  buried,  and  must  be 
attacked  carefully  yet  boldly.     If  the  cornea  should  be  per- 


MISCELLANEOUS  DISEASES  OF  THE  CORNEA.        73 

forated  and  the  foreign  body  lie  partly  in  the  anterior  cham- 
ber, it  must  not  be  pushed  further  in.  An  eye  drop  of  boric 
acid  (saturated  solution)  should  be  prescribed  and  the  eye 
bandaged. 

PERFORATING  WOUNDS  OF  THE  CORNEA. 

Wounds  which  open  the  anterior  chamber  and  allow 
the  aqueous  to  escape  are  likely  to  be  complicated  by  falling 
in  of  the  iris  (prolapse  of  the  iris).  If  the  wound  is  not 
ijifected  and  not  too  extensive  or  contused,  it  will  heal  in  a 
few  days,  and  when  the  iris  is  not  prolapsed  only  a  scar  will 
result.  This  may  or  may  not  affect  the  vision,  according  to 
its  situation.  If  there  is  prolapse  of  iris,  the  healing  will  not 
be  so  rapid,  and  danger  of  subsequent  inflammation  will  be 
incurred.  A  fistulous  opening  may  remain,  which  may  also 
happen  in  perforating  lUcers. 

Treatment. — The  wound  should  be  cleansed  with  an  anti- 
septic solution  (bichloride  of  mercury  1  :  5000),  which  should 
be  continued,  together  with  atropine  (1  per  cent.)  and  light 
pressure-bandage.  Ice  applications  may  be  employed  during 
the  first  day  or  two  to  control  reaction. 

Treatment  of  the  prolapsed  iris  is  important.  If  the  wound 
is  clean  and  the  case  is  seen  within  forty-eight  hours  of  the 
injury,  the  iris  should  be  pulled  through  the  wound  with  iris- 
forceps  and  cut  off  close  to  the  cornea  with  scissors.  The 
cut  edges  of  the  iris  must  be  carefully  replaced  within  the 
anterior  chamber  by  a  spatula.  If  the  wound  is  infected, 
the  iris  should  not  be  cut,  since  this  procedure  exposes  the 
tissues  to  infection,  which  otherwise  they  might  escape.  If 
the  case  is  over  forty-eight  hours  old,  adhesions  to  the  wound 
have  formed,  which  render  separation  of  the  iris  difficult,  and 
to  leave  the  cut  edges  of  the  iris  in  the  wound  opens  a  path 
for  infection  to  the  interior  of  the  eye. 

MISCELLANEOUS  DISEASES  OF  THE  CORNEA. 

Superficial  Keratitis. — Synonym. — Vascular  keratitis. 
Definition. — A  term  used  to  signify  a  superficial  inflamma- 


74  DISEASES  OF  THE  CORNEA. 

tion  such  as  that  which  complicates  trachoma,  otherwise  known 
as  pannus.  It  is  characterized  by  the  presence  of  bloodvessels 
and  infiltration  on  the  surface  of  the  cornea. 

Treatment  consists  in  attacking  the  trachoma,  but  in  severe 
cases  the  bloodvessels  may  be  cut  off  by  scraping  the  periphery 
of  the  cornea,  or  the  galvanocautery  may  be  used  for  the 
purpose. 

Vesicular  Keratitis. — A  number  of  diseased  conditions  of 
the  cornea  presenting  vesicle  formations  are  classed  under  this 
head. 

Herpes  cornese  is  a  peculiar  recurrent  eruption  of  small 
vesicles  on  the  surface  of  the  cornea  lasting  for  a  few  hours 
and  accompanied  by  sensations  of  a  foreign  body,  pain  and 
irritation,  which  pass  away  when  the  vesicle  ruptures.  It 
sometimes  follows  an  abrasion  or  injuries  of  the  cornea. 

Keratitis  Bullosa. — Characterized  by  large  bullae,  occur- 
ring usually  in  a  diseased  eye. 

Herpes  Zoster  Ophthalmicus. — When  herpes  affects  the 
fifth  nerve,  it  may  attack  the  cornea  as  well  as  the  skin  of  the 
face.     The  corneal  eruption  usually  leaves  scars. 

Treatment  of  vesicular  keratitis  is  in  general  similar  to  that 
of  ulcer  of  the  cornea. 

Filamentous  Keratitis. — Shows  threads  attached  at  one 
end  to  an  ulceration. 

Keratitis  profunda  is  a  deep-seated  central  interstitial 
keratitis  occurring  in  the  adult  and  sometimes  confounded 
with  keratitis  of  specific  origin.  The  cause  is  generally  un- 
known, but  it  may  be  due  to  exposure,  rheumatism,  or  malaria. 

Local  treatment  is  same  as  for  interstitial  keratitis. 

Sclerosing  keratitis  accompanies  scleritis  as  a  dense  white 
permanent  opacity  resembling  the  normal  sclera. 

Treatment  is  the  same  as  for  scleritis. 

Ribbon-shaped  Keratitis. — Synonjrm. — Transverse  cal- 
careous film. 

Definition. — A  grayish-white  band  extending  horizontally 
across  the  cornea.  It  is  hard  to  the  touch  of  an  instrument, 
since  it  contains  lime.  It  occurs  in  eyes  which  have  been 
diseased  or  are  degenerated. 


MISCELLANEOUS  DISEASES  OF  THE  CORNEA.        75 

Treatment  consists  in  scraping  off  the  film. 

Neuroparalytic  keratitis  is  due  to  lesion  of  the  trigeminus 
which  cuts  off  the  nerve-supply  of  the  cornea.  Characterized 
by  anaesthesia,  ulcerations,  and  necrosis  caused  by  trophic 
changes  and  undetected  foreign  bodies. 

Posterior  punctate  Keratitis. — Synonym. — Descemitis. 

Definition. — A  condition  in  which  minute  deposits  occur  on 
the  lower  part  of  the  posterior  surface  of  the  cornea  in  the 
form  of  a  triangle  with  the  base  down.  It  is  a  manifestation 
of  disease  of  the  uveal  tract — L  e.,  iris,  ciliary  body,  or  choroid 
(see  Serous  Iritis). 

Superficial  punctate  keratitis  is  characterized  by  numer- 
ous small  elevated  opacities  of  the  anterior  layers  of  the  cornea 
accompanied  by  congestion  and  irritation  of  the  eye. 

Tumors  of  the  cornea  are  of  rare  occurrence.  They  are 
found  mostly  at  the  limbus,  and  dermoid  fibroma,  papilloma, 
epithelioma  and  sarcoma  have  been  described. 

Pigmentation  of  the  Cornea. — The  cornea  may  be  stained 
with  blood-pigment  (hsematin,  hsematoidin),  or  from  the  pres- 
ence of  iris  or  steel  in  the  eye  (siderosis). 

Arcus  Senilis  (Gerontoxon). — A  zone  of  opacity  at  the 
periphery  of  the  cornea,  but  with  a  narrow  zone  of  clear  cornea 
between  it  and  the  sclera.  It  is  a  fatty  degeneration,  and  gen- 
erally found  in  elderly  persons. 

QUESTIONS. 

Mention  the  varieties  of  corneal  ulcers. 
Give  course,  complications,  and  treatment. 
Describe  interstitial  keratitis. 
Describe  phlyctenular  keratitis. 
Define  other  forms  of  keratitis. 
Define  staphyloma  and  keratoconus. 

State  rule  for  treatment  of  prolapse  of  iris  in  perforating  wounds  of  the 
cornea. 

What  is  arcus  senilis? 

What  antiseptics  are  used  in  treating  the  cornea  ? 


76  DISEASES  OF  THE  SCLERA. 

CHAPTER    VI. 

DISEASES  OF  THE  SCLERA. 

SCLERITIS. 

Definition. — A  localized  inflammation  charact€rized  by  the 
presence  of  more  or  less  elevated,  congested,  and  discolored 
patches  in  the  sclera. 

Etiology. — The  disease  occurs  in  adults  who  are  the  sub- 
jects of  constitutional  disorders,  such  as  syphilis,  rheumatism, 
malaria,  gout,  or  tuberculosis.     It  may  be  idiopathic. 

Varieties. — Episcleritis:  Involves  the  superficial  layers  of 
the  sclera.  Scleritis  proper:  Where  the  whole  depth  is 
affected.  A  clinical  variety  of  episcleritis  is  a  mild  recurrent 
form  called  episcleritis  fugax.  The  elevated  patches  of  spe- 
cific origin  may  be  called  gummatous  scleritis. 

Sjrmptoms. — I.  Episcleritis.  There  is  usually  only  a  moder- 
ate amount  of  pain,  photophobia,  and  irritation.  A  bright-red 
or  violet,  slightly  elevated  patch  appears  on  the  sclera  not  far 
from  the  cornea.  The  congestion  is  seen  to  be  formed,  not 
alone  by  the  conjunctival  vessels,  but  by  those  of  the  sclera 
underlying.  There  are  frequent  relapses.  II.  Scleritis.  This 
is  a  more  serious  form.  There  may  be  considerable  pain, 
tenderness,  photophobia,  lachrymation,  and  general  irritation. 
There  are  elevated,  red,  yellow,  or  violet  areas  in  the  sclera, 
which,  recurring,  may  extend  about  the  whole  cornea.  The 
deeper  structures — iris,  ciliary  body,  and  adjacent  cornea — are 
often  involved. 

Complications. — Scleritis,  iritis,  keratitis,  and  cyclitis — a 
process  affecting  the  anterior  segment  of  the  eyeball — is 
known  as  anterior  uveitis.  When  the  sclera  and  cornea 
alone  are  affected,  it  is  called  sclerokeratitis.  The  sclera  may 
be  thinned  by  inflammation  and  bulge  from  internal  pressure, 
producing  staphyloma.  Glaucoma  may  ensue  Patches  of 
scleritis  leave  permanent  dark-bluish  spots  at  the  site  of  the 
lesion,  which  should  not  be  confounded  with  congenital  pig- 
mentation. 


STAPHYLOMA-INJUBIES  OF  THE  SCLERA.  77 

Constitutional  treatment  should  be  given  according  to  the 
established  cause.  In  idiopathic  cases  sodium  salicylate,  gr.  x 
three  or  four  times  a  day  (although  some  advocate  very  large 
doses),  or  potass,  iodide,  gr.  x  t.  i.  d.,  is  indicated. 

Local  Treatment. — Hot  fomentations.  Atropine  (1  per 
cent.),  t.  i.  d.  Subconjunctival  injections  of  salt  solution  or 
bichloride  of  mercury  (1  :  5000)  may  be  tried. 

STAPHYLOMA. 

Definition. — A  bulging  of  the  sclera  not  due  to  thickening. 
It  occurs  after  scleritis ;  also  in  diseases  of  the  choroid  and 
ciliary  body  accompanied  by  high  tension,  or  in  weakening 
of  the  cornea  or  sclera  after  injury.  It  appears  as  dark 
bluish  elevations  (sometimes  called  ectasiae). 

Posterior  staphyloma  is  a  bulging  of  the  sclera  about  the 
optic  nerve,  and  is  associated  with  high  myopia.  (See  page 
132.) 

Treatment. — For  anterior  and  equatorial  staphyloma  with 
increased  tension  iridectomy  may  be  indicated  ;  but  if  the  eyes 
are  destroyed  by  inflammation  and  are  unsightly  or  painful, 
enucleation  is  necessary. 

INJURIES  OF  THE  SCLERA. 

The  sclera,  with  the  cornea,  is  exposed  to  injury  from  for- 
eign bodies.  Injuries  with  blunt  objects  may  produce  rupture 
of  the  eyeball,  which,  beside  the  lacerated  wound  usually  near 
the  cornea,  is  often  accompanied  by  internal  injuries,  such  as 
rupture  of  the  iris,  dislocation  of  the  lens,  detachment  of  the 
retina,  rupture  of  the  choroid,  or  intraocular  hemorrhage. 
The  eyeball  is  soft  and  the  vision  is  seriously  affected.  Rup- 
ture of  the  sclera,  without  break  of  the  conjunctiva,  is  pos- 
sible. 

Incised  wounds,  when  large,  are  accompanied  by  more  or 
less  loss  of  vitreous  and  prolapse  of  the  ciliary  body  and 
choroid.  The  greatest  danger  beside  that  arising  directly 
from  the  injury  is  from  infection,  which  may  produce  an 
iridocyclitis  or  panophthalmitis,  both  of  which  may  end  in 


78  DISEASES  OF  THE  IBIS. 

shrinking  of  the  eyeball  (phthisis  bulbi).  When  the  wound 
is  in  a  zone  occupying  about  one-fourth  of  an  inch  outside 
the  periphery  of  the  cornea  (known  as  the  "  ciliary  region '' 
on  account  of  the  fact  that  the  ciliary  body  lies  beneath  it), 
the  injury  has  a  further  significance.  Such  a  wound,  followed 
by  a  chronic  iridocyclitis,  gives  the  conditions  which  may 
produce  sympathetic  disease  in  the  other  eye — sympathetic 
ophthalmia.  If  a  foreign  body  is  retained  within  the  eye, 
the  case  is  further  complicated.     (See  page  118.) 

Treatment. — Small  wounds  should  be  treated  with  pressure- 
bandage,  an  antiseptic  (bichloride  1  :  5000),  and  atropine 
(1  per  cent.).  In  extensive  wounds,  say  over  10  mm.,  sutures 
should  be  passed  through  the  scleral  edges  of  the  wound  and 
others  through  the  conjunctiva.  These  wounds  sometimes 
heal  remarkably  well.  If  the  ciliary  body  or  choroid  is 
prolapsed,  it  should  be  cut  off.  When  an  injury  has  evi- 
dently completely  destroyed  the  eye,  it  should  be  enucleated 
at  once. 

QUESTIONS. 

What  are  the  varieties  of  scleritis? 
Describe  each. 

Define  staphyloma  of  the  sclera. 

Give  differential  diagnosis  between  episcleritis  and  phlyctenular  conjuncti- 
vitis. 

Describe  injuries  of  the  sclera  and  give  treatment. 


CHAPTER   yil. 

DISEASES  OF  THE  IRIS. 

IRITIS. 

Varieties. — In  point  of  duration  and  severity  iritis  may 
be  divided  into  acute,  subacute,  and  chronic.  As  regards 
etiology,  into  syphilitic,  rheumatic,  gonorrhoeal,  traumatic, 
tuberculous,  secondary,  sympathetic,  and  idiopathic.  On  a 
pathologic  basis,  into  plastic,  serous,  and  purulent. 


ACUTE  PLASTIC  IRITIS.  79 


ACUTE  PLASTIC  lEITIS. 


Definition. — An  inflammation  of  the  iris,  characterized  by 
congestion,  small  pupil,  and  posterior  synechiae. 

Etiology. — The  disease  occurs  in  the  secondary  stage  of 
syphilis — /.  e.,  from  the  second  to  the  eighteenth  month — and 
is  rarely  seen  in  the  tertiary  stage.  Rheumatism  is  the  next 
most  frequent  cause.  It  may  occur  with  gonorrhoeal  rheu- 
matism, but  not  usually  at  the  same  time.  It  may  appear  in 
diabetes,  gout,  or  from  traumatism,  or  may  be  idiopathic.  It 
may  also  be  secondary  to  inflammation  of  adjacent  tissues — 
e.  g.,  in  keratitis  or  scleritis. 

Pathology. — The  iris  is  congested,  swollen,  and  infiltrated 
with  round  cells.  There  is  an  exudate  of  round  cells,  fibrin, 
and  pigment-cells,  which  fills  the  anterior  chamber  and  glues 
the  edge  of  the  pupil  and  back  of  the  iris  to  the  anterior  cap- 
sule of  the  lens. 

Subjective  Symptoms. — The  patient  complains  of  more  or 
less  severe  pain  in  the  eye,  forehead,  and  temple,  especially  in 
the  early  hours  of  the  morning.  There  are  fear  of  light  and 
lachrymation.  The  vision  is  affected,  and  there  may  be  some 
constitutional  symptoms. 

Objective  Sjrmptoms. — On  examination  the  lids  are  found  to 
be  swollen  and  red.  The  eyeball  shows  the  typical  circum- 
corneal  or  ciliary  congestion,  with  some  congestion  of  the  con- 
junctiva. The  cornea  under  oblique  illumination  is  seen  to 
be  hazy,  and  under  careful  examination  the  posterior  surface 
will  often  be  found  studded  with  minute  dots.  The  anterior 
chamber  is  cloudy,  and  there  may  be  some  deposits  in  the 
lower  part.  Rarely  blood  may  be  seen  in  the  anterior  cham- 
ber. The  anterior  surface  of  the  iris  has  lost  its  fine  and 
delicate  details.  It  looks  muddy,  and  has  changed  to  a  dirty 
color  as  compared  with  the  other  eye.  The  pupil  is  small, 
and  scarcely  moves  to  stimulus  of  light.  It  is  more  or  less 
filled  with  cloudy  exudate.  If  a  drop  of  a  mydriatic,  such 
as  atropine  (1  per  cent),  be  instilled,  the  pupil  will  show 
irregular  dilatation  on  account  of  the  fact  that  at  dift'erent 
points  the  pupillary  edge  of  the  iris  is  held  to  the  lens  by 


80  DISEASES  OP  THE  iRtS. 

exudate  (posterior  synechise).  If  these  be  torn  oif  by  the 
action  of  the  mydriatic,  it  is  common  to  find  a  ring  of  pig- 
ment corresponding  to  the  position  of  the  edge  of  the  iris 
before  treatment  was  begun.  On  account  of  the  hazy  condi- 
tion of  the  media  the  fundus  is  usually  obscured.  A  form 
of  the  disease  known  as  spongy  iritis  occurs  especially  after 
injuries  and  operations  which  open  the  anterior  chamber.  It 
is  characterized  by  a  gelatinous  sharply  defined  mass  of 
exudate  in  the  anterior  chamber,  which  resembles  a  partly 
opaque,  dislocated  lens.  It  often  disappears  with  great 
rapidity. 

Course. — The  disease  may  occur  at  any  time  of  life,  but  is 
uncommon  in  children,  except  as  a  secondary  condition.  It 
begins  acutely  and  lasts  from  one  to  six  weeks. 

Prognosis. — When  seen  early,  the  prognosis  is  excellent  if 
proper  treatment  is  carried  out.  There  is  a  tendency  to 
recurrence. 

Complications. — If  the  disease  is  severe,  there  may  be  formed 
numerous  synechiae  and  more  or  less  deposit  in  the  pupillary 
area.  If  the  blocking  of  the  pupil  is  complete,  it  is  known 
as  occlusion ;  if  the  synechise  completely  bind  down  the  iris 
yet  leave  the  pupil  clear,  the  condition  is  called  exclusion. 
In  the  latter  circumstances  circulation  from  behind  the  iris 
through  the  pupil  is  impeded,  and  the  iris  bulges  forward  into 
the  anterior  chamber,  except  at  the  pupillary  edge ;  hence  the 
name  crater-shaped  pupil  (iris  bombQ.  Glaucoma  is  likely  to 
follow,  and  the  condition  must  be  relieved  by  iridectomy. 
After  repeated  attacks  of  iritis  the  iris  may  become  atrophic 
and  immovable.  Cataract  may  also  form.  Adjacent  tissues 
may  be  involved  in  the  inflammatory  process,  and  the  condi- 
tions are  designated  by  the  following  terms,  which  are  self- 
explanatory  :  iridocyclitis,  iridochoroiditis,  keratoiritis,  ante- 
rior uveitis.  (See  page  76.)  In  syphilitic  iritis  yellow 
nodules  form  at  the  pupillary  margin  or  at  the  periphery. 
Gummata  may  develop  in  tertiary  syphilis. 

Diagnosis. — The  pain,  especially  at  night,  the  ciliary  conges- 
tion, muddy  iris,  small  pupil,  and  especially  posterior  syne- 
chise establish  the  diagnosis. 


u- 


ACUTE  PLASTIC  IMIS.  81 

Differential  Diagnosis. — See  Acute  Glaucoma. 

Treatment. — Patients  should  be  kept  in  a  darkened  room, 
and,  if  the  attack  is  severe,  in  bed. 

Constitutional  treatment  should  be  instituted  according  to  the 
cause.  Syphilis  must  be  treated  energetically  with  mercury 
protiodide  (^  gr.),  bichloride  (^V  gr-)>  inunctions  of  blue  oint- 
ment, or  hypodermatic  injections  of  bichloride.  Potassium 
iodide  may  also  be  given  (gr.  x,  increased).  In  rheumatic 
cases  it  is  well  to  give  the  patient  a  saline  cathartic  at  the 
beginning  of  the  treatment,  followed  by  salicylates,  such  as 
sodium  salicylate,  30  to  60  grains  daily.  In  idiopathic  and 
gonorrhoeal  cases  salicylates  are  also  indicated.  Morphine 
may  be  necessary  to  quiet  pain. 

Local  Treatment. — Dry  or  moist  heat  should  l)e  applied. 
In  severe  cases  leeches  may  be  placed  near  the  outer  can- 
thus.  Atropine  is  most  essential  (1  per  cent,  solution),  and 
should  be  dropped  into  the  eye  three  to  six  times  a  day, 
depending  on  the  severity  of  the  attack  and  the  ease  with 
which  the  pupil  is  dilated.  A  local  toxic  effect  is  sometimes 
noticed  in  the  form  of  conjunctivitis,  swelling  and  redness  of 
the  lids.  In  this  case  scopolamine  (1  per  cent.)  or  duboisine 
(1  per  cent.)  may  be  substituted.  Atropine  also  sometimes 
produces  a  granular  conjunctivitis  resembling  trachoma  (papil- 
lary conjunctivitis).  Disagreeable  effects  from  absorption  are 
at  times  noticed — dryness  of  the  tongue  and  constitutional 
effects,  as  flushed  face,  dizziness,  and  rapid  pulse.  Small 
doses  of  morphine  and  pilocarpine  are  then  indicated. 

Chronic  Plastic  Iritis. — Iritis  may  assume  the  chronic 
form,  most  commonly  in  elderly  rheumatic  subjects.  The 
exacerbations  are  frequent,  but  usually  not  severe ;  however, 
each  attack  thickens  the  pupillary  membrane,  and  finally 
leads  to  occlusion,  glaucoma,  and  loss  of  the  eye.  Under  this 
head  may  be  included  the  iritis  of  sympathetic  ophthalmia 
(page  125). 

Treatment. — Chronic  iritis  is  best  treated  by  atropine,  anti- 
rheumatic remedies,  and  by  making  an  iridectomy. 

6— E.  E. 


82  DISEASES  OF  THE  lEIS. 

SEROUS  IRITIS. 

Synonyms.  —  Keratitis  punctata  posterior ;  Descemitis ; 
Aquocapsulitis. 

Definition  and  Symptoms. — Serous  iritis  is  the  term  used  to 
describe  a  condition  in  which  the  eye  shows  only  slight  ciliary 
congestion ;  numerous  deposits  of  various  sizes  on  the  pos- 
terior surface  of  the  cornea,  which  occupy  the  lower  half  of 
the  cornea  in  a  triangular  shape,  with  the  base  down  at  the 
periphery  and  the  apex  at  the  centre  of  the  cornea ;  also  a 
deep  anterior  chamber  and  somewhat  enlarged  pupil.  This 
condition  is  now  known  to  be  a  serous  inflammation  of  the 
uveal  tract,  including  the  posterior  layer  of  epithelial  cells  of 
the  cornea,  the  iris,  ciliary  body,  and  probably  the  choroid. 

Treatment. — Atropine  must  be  used  with  caution,  owing  to 
glaucomatous  tendencies.  General  treatment  is  the  same  as 
for  plastic  iritis. 

Purulent  Iritis. — Purulent  iritis  is  defined  as  a  purulent 
inflammation,  the  result  of  infection,  generally  following  per- 
forating injuries,  but  may  occur  as  a  metastatic  process  in 
infectious  diseases;  often  associated  with  purulent  processes 
in  the  deeper  structures — choroid  and  vitreous.     Hypopyon 

is  present. 

TUBERCULOUS  IRITIS. 

Varieties. — Tuberculosis  rarely  attacks  the  eye,  but  may 
occur  in  the  iris  under  two  forms.  I.  Isolated  tubercles,  which 
appear  as  yellow  tumors  usually  at  the  periphery  of  the  iris. 
They  gradually  increase  in  size,  with  slight  inflammatory 
symptoms.  They  involve  the  cornea  and  deeper  structures, 
finally  destroying  the  eye.  Spontaneous  absorption  has  been 
known  to  occur.  11.  Miliary  tuberculosis  of  the  iris  is  the 
other  form.  It  presents  the  signs  of  acute  iritis  without  much 
pain.  The  surface  of  the  iris  is  studded  with  small  yellow- 
ish-gray elevations  (tubercles).  Infiltration  of  the  eye  with 
tuberculous  tissue  usually  supervenes,  and  the  eye  is  lost. 
Cases  of  spontaneous  recovery  are  not  uncommon.  The  dis- 
ease of  the  eye  is  undoubtedly  always  secondary  to  tuber- 
culous deposits  in  other  parts  of  the  body. 


INJURIES  AND  TUMORS  OF  THE  IRIS.  83 

Treatment  is  the  same  as  of  other  forms  of  iritis,  with 
proper  constitutional  treatment.  Enucleation  may  be  thought 
ad  visible  in  advancing  cases  to  prevent  general  infection. 

INJURIES  OF  THE  IRIS. 

Concussion  of  the  eyeball  may  produce  a  dilatation  of  the 
pupil,  sometimes  irregular.  This  is  due  to  paralysis  of  the 
sphincter  pupillse.  It  generally  disappears.  The  pupillary 
edge  may  be  torn  in  the  form  of  one  or  more  rents,  or  the 
iris  may  be  separated  at  the  periphery  from  its  root,  leaving 
a  clear  space  (iridodialysis).  It  may  be  entirely  torn  from  its 
attachment  (traumatic  irideremia). 

Perforating  wounds  are  usually  accompanied  by  injury  of 
the  lens  and  other  structures.  Wounds  of  the  cornea  are 
often  complicated  by  the  falling  in  of  the  iris  (prolapse), 
the  treatment  of  which  has  been  described  (page  73).  A 
small  foreign  body  passing  through  the  cornea  and  iris  leaves 
a  perforation  which  is  of  diagnostic  value  in  reference  to  the 
presence  of  a  foreign  body  in  the  eye.  The  greatest  danger 
from  wounds  is  from  infection,  which,  if  it  reaches  the  iris, 
usually  produces  purulent  iritis.  When  the  lens  is  dislocated 
or  absent,  the  iris,  being  without  support,  will  tremble  with 
every  movement  of  the  eye  (tremulous  iris,  iridodonesis).  In 
some  injuries,  and  occasionally  after  extraction  of  cataract, 
with  loss  of  vitreous,  a  part  of  the  iris  may  be  folded  back 
upon  itself,  thus  enlarging  the  pupil  in  that  part  (retroflexion). 

TUMORS  OF  THE  IRIS. 

Apart  from  the  syphilitic  and  tuberculous  tumors  of  the 
iris  already  described,  tumors  of  the  iris  are  of  rare  occur- 
rence. 

Sarcoma,  usually  melanosarcoma,  occurs  at  any  age,  but 
usually  in  middle  life. 

Melanoma  is  a  benign,  nonprogressive  pigmented  tumor. 

Cysts. — Transparent  or  true  cysts  of  the  iris  may  be  con- 
genital, but  are  usually  traumatic.  They  may  occur  from  the 
presence  of  a  foreign  body  (transplantation  cyst). 


84  I>ISEAS£:S  OF  THE  PUPIL. 

Differential  Diagnosis  of  Tumors  of  the  Iris. — Tubercles  occur 
in  youth  at  the  periphery  of  the  iris,  secondary  to  other  tuber- 
culous disease ;  bright  yellow  or  gray  color,  with  an  occasional 
vessel  running  over  the  surface ;  associated  with  serous  iritis ; 
gradually  infiltrate  the  surrounding  tissues ;  may  disappear ; 
rupture  through  limbus. 

Gummata. — Occur  in  middle  life  in  the  tertiary  stage  of 
syphilis ;  dark  yellow  color  at  the  pupillary  edge  or  at  the 
periphery  ;  break  down  or  absorb. 

Sarcomata. — Dark,  usually  ;  middle  and  late  life  ;  lower  part 
of  the  iris ;  vascular ;  rarely  burst  through  the  cornea ;  pro- 
gressive. 

Cysts. — Transparent ;  usually  following  injury. 

Congenital  Defects  of  the  Iris. — The  iris  is  rarely  entirely 
wanting  at  birth  {irideremia,  aniridia).  A  part  of  the  iris 
from  the  periphery  to  the  edge  of  the  pupil  may  be  congeni- 
tally  absent  (colohoma  of  the  iris).  This  occurs  in  the  inferior 
nasal  quadrant.  The  pupil  may  be  irregularly  placed  (cor-ec- 
topia)  or  multiple  (polycoria).  There  may  be  remnants  of  the 
pupillary  membrane  stretching  across  the  pupil  (persistent 
pupillary  membrane). 


CHAPTER  VIII. 
DISEASES  OF  THE  PUPIL. 
PHYSIOLOGY. 
Contraction. — The  contraction  of  the  pupil  is  caused  by 
the  action  of  the  sphincter  pupillse.     I.  If  light  falls  upon  the 
retina,  the  pupil  contracts  by  reflex  action.     The  course  of 
the  impulse  starting  in  the  retina  and  ending  in  the  contrac- 
tion of  the  sphincter  is  as  follows  :  From  the  retina  it  travels 
through   the   optic   nerve   and    optic   tract   to   the    anterior 
corpus  quadrigeminum  (probably).     From   there  the   pupil- 
fibres  pass  by  Meynert's  fibres  to  the  centre  of  the  sphincter 
pupillse  in  the  third  nerve  nucleus.     Here  the  reflex  is  started, 
which  passes  out  to  the  eye  by  the  third  nerve  and  its  ciliary 


PHYSIOLOGY.  86 

fibres.  The  contraction  to  light  of  the  pupil  of  the  eye  illumi- 
nated is  called  the  direct  action,  but  the  other  pupil  also  con- 
tracts at  the  same  time.  This  is  called  the  consensual  action. 
It  is  explained  by  the  fact  that  the  pupillary  fibres  of  the 
optic  nerve  probably  suffer  semidecussation  at  the  chiasm  as 
well  as  the  visual  fibres.  There  is  also  a  communication 
between  the  two  corpora  quadrigemina  and  between  the  third 
nerve  nuclei.  II.  The  pupil  contracts  not  only  to  light,  but 
also  to  convergence  and  accommodation.  It  seems  probable 
that  the  three  centres  for  convergence,  accommodation,  and 
pupil-contraction,  though  independent,  are  stimulated  simulta- 
neously by  the  voluntary  impulse  for  adjustment  of  the  eyes 
for  the  near  point. 

Dilatation. — The  presence  of  a  dilator  muscle  is  still  in 
doubt.  The  elasticity  of  the  posterior  membrane  and  vaso- 
motor action  are  probably  in  part  active  in  dilatation.  Dila- 
tation is  under  the  control  of  the  sympathetic  system.  The 
centre  is  in  the  medulla  and  the  course  is  down  the  spinal 
cord  to  the  seventh  and  eighth  cervical  and  first  dorsal  roots, 
through  the  cervical  sympathetic,  carotid,  and  cavernous 
plexus  to  the  eye.  Physiologic  dilatation  is  produced  by 
irritation  of  sensory  nerves  and  by  psychic  conditions  such 
as  fright  or  anger. 

Size  of  the  Pupil. — There  is  no  standard  size  so  varied 
are  the  influences  acting  upon  the  pupil.  In  middle  life, 
with  moderate  illumination  and  the  accommodation  at  rest,  it 
is  from  4  to  4.5  mm.  in  diameter.  In  children  it  is  larger 
than  in  the  adult. 

Pathology. — The  state  of  dilated  pupil  is  called  mydn- 
asis ;  of  contracted  pupil,  7nyosis.  Bearing  in  mind  the 
physiology,  it  will  be  readily  seen  that  mydriasis  may  be 
produced  by  (a)  paralysis  of  the  third  nerve  or  those  fibres 
going  to  the  sphincter  pupillse,  or  by  (6)  stimulation  of  the 
sympathetic  fibres  or  the  dilator  fibres.  On  the  other  hand, 
myosis  may  be  produced  by  (a)  paralysis  of  the  sympathetic 
fibres  or  (6)  irritation  of  the  third  nerve.     Hence  we  have : 

Mydriasis  .  |  P^'^lyt!";         Mvosis  .     .  |  Paralytic. 
y  \  Spasmodic.  "  ( bpasmodio. 


86  DISEASES  OF  THE  CILIARY  BODY. 

Paralytic  mydriasis  will  be  produced  by  lesions  involving 
the  third  nerve  or  its  centre,  such  as  tumors,  locomotor  ataxia, 
disseminate  sclerosis,  hemorrhages,  or  injuries ;  also  by  lesion 
of  the  optic  nerve  or  tract  and  by  paralysis  of  the  sphincter. 

Spasmodic  mydriasis  may  be  due  to  high  intracranial 
pressure,  spinal  irritation,  mental  excitability. 

Paralytic  Myosis. — Diseases  of  the  upper  portion  of  the 
spinal  cord. 

Tumors  or  wounds  involving  the  cervical  sympathetic. 

Spasmodic  Myosis. — Meningitis  in  the  early  stage.  Irri- 
tation of  the  third  nerve  or  centre  by  lesions  in  the  vicinity. 
As  a  reflex  from  irritation  in  the  eye,  as  from  a  foreign  body. 

The  so-called  Argyll-Robertson  pupil  does  not  contract  to 
light,  but  does  contract  to  accommodation.  It  is  principally 
found  in  locomotor  ataxia. 

Hippus  is  the  alternate  contraction  and  dilatation  of  abnor- 
mal amplitude. 

QUESTIONS. 

What  is  the  classification  of  iritis? 

Give  the  etiology,  pathology,  symptoms,  complications,  and  treatment  of 
acute  plastic  iritis. 
Define  serous  iritis. 
Name  two  forms  of  tuberculous  iritis. 
What  is  iridodialysis?    Iridodonesis  ?    Irideremia? 
Mention  the  tumors  of  the  iris.     Name  the  congenital  defects. 
Describe  the  physiologic  contraction  of  the  pupil  to  light. 
What  are  the  direct  and  the  consensual  actiou  of  the  pupil  to  light? 
Explain  contraction  to  accommodation. 
Explain  physiologic  dilatation. 

What  are  the  pathologic  states  of  contracted  and  dilated  pupil? 
Give  examples  of  each. 
What  is  the  Argyll-Robertson  pupil  ? 


CHAPTER  IX. 


DISEASES   OF  THE  CILIAEY   BODY. 
CYCLITIS. 

The  ciliary  body  is  in  close  anatomic  relations  on  the 
one  side  with  the  iris  and  on  the  other  with  the  choroid.  It 
is  not  strange  that  it  should  be  rarely  alone  affected. 


INJURIES  OF  THE  CILIARY  BODY.  87 

Varieties. — Cyclitis  is  usually  divided  into  plastic,  serous, 
and  purulent. 

ACUTE  PLASTIC  CYCLITIS. 

Definition. — This  disease  is  characterized  by  pain  in  the 
ciliary  region,  circunicorneal  congestion,  and  tenderness  over 
the  ciliary  body.  There  are  usually  some  opacities  in  the 
anterior  part  of  the  vitreous.  Glaucoma  is  not  an  uncommon 
complication.  If  the  iris  is  involved,  the  symptoms  of  iritis 
are  added.  When  the  choroiditis  accompanies  the  cyclitis, 
patches  of  exudate  may  be  seen  if  the  vitreous  opacities  will 
allow  inspection  of  the  fundus.  Tiie  causes  are  the  same  as 
in  acute  iritis.  If  the  disease  is  severe,  the  prognosis  is  bad, 
for  permanent  blocking  of  the  pupil  may  occur  and  permanent 
opacities  of  the  vitreous  may  result. 

Chronic  Plastic  Cyclitis. — Definition  and  Symptoms. — 
Usually  the  iris  is  involved.  There  are  occlusion  of  the  pupil 
and  formation  of  exudate  in  the  vitreous  back  of  the  lens, 
which  tends  to  organize  and  draw  together  the  ciliary  body. 
The  periphery  of  the  iris  is  retracted.  Such  a  chronic  irido- 
cyclitis of  traumatic  origin  may  produce  sympathetic  oph- 
thalmia. 

Serous  cyclitis  is  the  same  as  the  so-called  serous  iritis, 
and  is  described  under  that  head. 

PURULENT  CYCLITIS. 

Definition. — Usually  the  whole  uveal  tract  is  involved  in 
the  purulent  inflammation — iris,  ciliary  body,  and  choroid. 
This  condition  is  generally  due  to  a  perforating  injury,  but 
may  occur  as  a  metastatic  condition,  as  in  nasal  disease  or 
meningitis  (see  Purulent  Choroiditis). 

Treatment  of  cyclitis  is  the  same  as  for  iritis. 

INJURIES  OF  THE  CILLA.RY  BODY. 

The  ciliary  body  lies  behind  a  zone  which  surrounds  the 
cornea,  and  is  ^boiit  one-fourth  of  an  inch  wide  ("danger 


88  DISEASES  OF  THE  LENS. 

zone").  Perforating  wounds  in  this  region,  followed  by 
chronic  iridocyclitis,  give  the  conditions  which  cause  sympa- 
thetic ophthalmia. 

Wounds  with  or  without  prolapse  of  the  ciliary  body  should 
be  treated  according  to  the  rules  laid  down  under  injuries  of 
the  iris. 

TUMORS  OF  THE  CILIARY  BODY. 

Sarcomata,  usually  melanosarcoma,  are  of  rare  occurrence. 
Tubercles,  gummata,  and  cysts  have  been  reported.  These 
may  grow  into  the  vitreous  or  may  present  in  the  anterior 
chamber  at  the  periphery  of  the  iris. 

QUESTIONS. 

Define  plastic,  serous,  and  purulent  cyclitis. 

What  importance  have  wounds  in  the  ciliary  region? 


CHAPTER  X. 
DISEASES  OF  THE  LENS. 

CATARACT. 

Definition. — An  opacity  of  the  crystalline  lens  or  its  capsule. 
Varieties. — Cataracts  may  be  divided  into  polar,  anterior  and 
'posterior  (including  capsular),  zonular,  senile,  and  traumatic. 
Cataracts  may  also  be  classified  as  stationary  (polar  and  zonu- 
lar) and  progressive  (senile  and  traumatic).  When  a  cataract 
forms  without  known  connection  with  other  disease  of  the  eye, 
it  is  called  primary.  If  associated  with  glaucoma,  iridocycli- 
tis, tumors,  etc.,  it  is  called  secondary. 

ANTERIOR  POLAR  CATARACT. 

Sjmonym. — Pyramidal  cataract. 

Definition. — Under  oblique  illumination  a  small  round 
dense  opacity  is  seen  at  the  anterior  pole  of  the  lens.  This 
is  often  elevated  above  the  level  of  the  anterior  capsule 
(although  the  capsule  passes  over  it).     It  also  extends  som^- 


POSTERIOR  POLAR  AND  ZONULAR  CATARACT.       89 

what  into  the  sul)stance  of  the  lens.     An  opacity  of  the  cornea 
will  also  generally  be  found  near  the  centre. 

Etiology. — Anterior  polar  cataract  may  be  congenital  or 
acquired.  It  usually  originates  from  the  contact  of  the  lens 
with  the  posterior  surface  of  the  cornea  after  the  perforation 
of  an  ulcer  in  infancy  or  in  utero. 

Fig.  18. 


Anterior  polar  cataract,  seen  from  the  front  and  in  section.    (Nettleship.) 

Symptoms. — There  may  be  little  interference  with  vision  on 
account  of  the  fact  that  the  opacity  is  so  near  the  nodal  point. 
Treatment  is  not  necessary. 

POSTERIOR  POLAR  CATARACT. 

Definition  and  Symptoms. — May  be  somewhat  similar  to 
anterior  polar  cataract  in  appearance. 

The  congenital  form  appears  as  a  small  white  round  opacity, 
and  is  due  to  the  remains  of  the  point  of  contact  of  the  hyaloid 
artery,  which  extends  in  foetal  life  from  the  optic  nerve 
through  the  vitreous  to  the  posterior  surface  of  the  lens.  A 
minute  dot  is  very  common  on  the  posterior  capsule  in  normal 
eyes,  and  is  of  similar  origin.  An  acquired  form  is  associated 
with  intraocular  disease.  Cataracts  beginning  in  the  posterior 
cortex  or  upon  the  posterior  capsule  are  often  found  associated 
with  choroidal  disease,  and  may  clear. 

ZONULAR  CATARACT. 

Definition. — Zonular  or  lamellar  cataract  consists  of  one  or 
more  opaque  zones,  which  surround  a  clear  nucleus  and  leave 
an  outside  or  cortical  zone  clear. 

Symptoms. — By  oblique  illumination  the  opacity  may  be 
seen  to  be  lamellar  in  structure,  often  with  striae  running  out 


90 


DISEASES  OF  THE  LENS. 


into  the  clear  cortex.  The  extent  and  density  of  the  opacity 
are  subject  to  considerable  variation.  These  cataracts  are, 
almost  without  exception,  stationary.  Congenital  cataract 
may  also  show  complete  opacity  of  the  lens.  A  punctate 
and  a  stellate  form  about  the  nucleus  exist. 

Etiology. — Generally  congenital ;  sometimes  in  children  who 
have  suffered  from  convulsions  in  infancy  and  in  rachitis. 
There  is  an  hereditary  tendency. 

Treatment  depends  upon  the  extent  of  the  opacity.  If  the 
central  opacity  is  less  than  the  size  of  the  medium  pupil,  and 
if  atropine,  by   dilating   the   pupil,  allows   sufficient  vision 

Fig.  19. 


Discission  of  cataract.    (Juler.) 

through  the  clear  cortex  thus  exposed,  an  iridectomy  to  pro- 
duce artificial  pupil  will  be  the  proper  treatment.  The  ad- 
vantages of  this  method  of  treatment  are  that  the  accommo- 
dation is  left  intact,  and  no  glasses  need  necessarily  be  worn. 
If  the  opacity  is  too  extensive  to  obtain  clear  vision  through 
an  artificial  pupil,  the  lens  should  be  removed  by  absorption. 
The  operation  for  absorption  by  needling  (discission)  is  per- 
formed as  follows :  The  pupil  is  dilated  by  atropine.  The 
j)atient,  if  too  young  for  self-control,  should  be  put  under  a 
general  anaesthetic.  The  cornea  should  be  entered  by  a  knife- 
needle  which  has  a  short,  narrow  blade  and  a  long  shank.  A 
horizontal  incision  is  then  paade  through  the  ^nt^rior  capsule 


SENILE  CATARACT.  91 

and  somewhat  into  the  lens  substance.  It  should  be  about  4 
mm.  in  length.  A  vertical  cross -incision  may  also  be  made  if 
desired.  The  aqueous  humor  entering  into  the  lens  substance 
swells  and  gradually  dissolves  it.  If  the  swelling  is  too 
rapid,  glaucoma  may  ensue,  in  which  case  the  lens  must  be 
let  out  through  a  corneal  incision.  A  second  and  sometimes 
a  third  needling  is  necessary  before  the  lens  is  completely 
absorbed.  A  strong  convex  lens  must  then  be  worn  to  re- 
place the  crystalline  lens.  Iritis  may  rarely  complicate  the 
operation. 

SENILE  CATARACT. 

Etiology. — Although  cataracts  under  this  category  may 
occur  at  an  earlier  period,  the  vast  majority  are  found  after 
fifty  years  of  age.  They  are  most  frequent  among  the  aged  ; 
in  fact,  elderly  persons  are  likely  to  show  some,  practically 
stationary,  opacities  at  the  periphery  of  the  lens.  There  are 
usually  no  causes  to  assign  for  senile  cataracts.  They  appear 
equally  in  all  conditions  of  life,  although  constitutional  dis- 
eases, such  as  diabetes  and  tendencies  tow  ard  sclerotic  changes, 
are  known  to  favor  their  development. 

Pathology. — Between  the  ages  of  thirty  and  forty  the  lens 
begins  to  harden  at  its  centre,  forming  what  is  known  as  the 
nucleus.  The  size  of  the  nucleus  increases  with  age.  Cata- 
racts are  produced  during  the  process  of  nucleus-formation  by 
the  irregular  shrinking  of  the  fibres  and  the  collection  of  fluid 
within  spaces  thus  formed.  Degeneration  of  the  fibres  and 
coagulation  of  the  fluid  follow,  producing  opacities.  The 
choroid,  especially  at  its  periphery,  is  at  times  found  aff'ected 
during  the  formation  of  cataract. 

Subjective  Symptoms. — The  patient  complains  of  blurred 
vision,  flashes  and  streaks  of  light,  dark  spots,  and  double  or 
multiple  vision.  There  is  never  any  pain  directly  due  to 
cataract.  There  is  sometimes  eye-strain,  due  to  imperfect 
sight.  Sometimes  the  first  subjective  symptom  is  the  ability 
to  read  without  glasses  (second  sight).  This  is  due  to  the 
increased  refracting  power  of  the  lens  from  swelling. 

Objective  Symptoms. — 1.  In  the  early  stages  {incipient  cata- 


92  DISEASES  OF  THE  LENS. 

ract)  an  opacity  may  be  found  at  the  centre  of  the  lens  (nuclear), 
or  radiating  spiculse  may  be  seen  in  the  cortex  (cortieal),  or 
again  a  homogeneous  or  mottled  opacity  may  appear  through- 
out the  whole  lens.  These  changes  may  be  best  made  out 
with  the  dilated  pupil  by  oblique  illumination,  in  which  case 
the  opacities  appear  white,  or  by  the  ophthalmoscope,  in 
which  case  they  appear  black  against  the  red  reflex  from  the 
fundus.  In  elderly  persons  a  brownish-red  appearance  with- 
out decided  opacity  may  often  be  made  out,  especially  in  the 
centre  of  the  lens.  This  is  due  to  sclerosis  (sclerosed  cataract). 
Such  a  lens  may  appear  almost  black  when  extracted  (cata- 
racta  nigra).  II.  As  the  ripening  process  advances  (immature 
cataract),  the  lens  becomes  more  extensively  opaque  and  at 
the  same  time  increases  in  size  (cataracta  tumefacta).  This 
swelling  of  the  lens  is  manifest  in  the  decreased  depth  of  the 
anterior  chamber — i.  e.,  the  iris  is  pushed  toward  the  cornea. 
The  reflex  from  the  fundus  is  gradually  lost  and  the  opacity 
becomes  quite  evident  in  daylight.  At  times  it  has  a  streaked, 
glistening  appearance  (asbestiform).  III.  The  cataract  then 
gradually  shrinks  to  its  normal  or  somewhat  less  than  normal 
size.  It  is  fully  opaque  and  "ripe"  (mature  cataract).  A 
sclerosed  cataract  never  becomes  opaque,  but  translucent,  and 
vision  is  never  entirely  lost.  IV.  If  allowed  to  remain,  the 
cortex  slowly  softens  (hypermature  cataract)  and  may  become 
fluid,  leaving  the  hard  nucleus  to  float  about  (3Iorgagnian 
cataract),  or  the  lens  may  become  flat  (disciform)  or  calcify. 

Course. — The  progress  of  senile  cataracts  is  slow.  A  num- 
ber of  years  usually  pass  before  maturity  is  reached.  They 
may  become  stationary  at  any  time.  They  probably  never 
actually  improve,  although  a  few  such  instances  have  been 
reported.  The  rapidity  of  progress  is  usually  difficult  to 
estimate  by  one  examination,  but  in  general  sharply  outlined 
cortical  and  well-defined  punctate  opacities  are  stationary. 
Diff'used  blurred  opacities  are  progressive.  In  senile  cataract 
both  eyes  are  affected  sooner  or  later,  although  it  often  hap- 
pens that  one  eye  may  become  fully  mature  before  the  other 
eye  is  materially  changed. 

Pro^osis, — The  points  to  be  noticed  before  expressing  ap 


SENILE  CATARACT.  93 

opinion  as  to  the  suitableness  of  a  cataract  for  operation  are 
as  follows:  The  eye  should  be  free  from  evidence  of  disease 
as  far  as  one  is  able  by  external  examination  to  exclude  it — 
i.  e.,  dacryocystitis,  conjunctivitis,  corneal  affections,  signs  of 
iritis,  such  as  synechise  (cataracta  accreta)^  The  anterior 
chamber  should  be  of  normal  depth.  The  pupil  should  react 
to  light.  There  should  be  a  homogeneous  white  or  gray 
opacity  immediately  back  of  the  pupil,  with  no  shadow  from 
the  edge  of  the  pupil  except  in  cases  of  sclerosis  already  men- 
tioned. A  candle  carried  on  all  sides  of  the  patient  while  the 
eye  is  fixed,  should  be  properly  located  by  him  (projection 
good).     The  tension  of  the  eyeball  should  be  normal. 

If  the  above  examination  of  the  eye  prove  satisfactory,  the 
cataract  is  ripe,  and  in  all  probability  vision,  after  operation, 
will  be  good.  95  per  cent,  of  success  is  an  average  showing. 
It  is  of  some  importance  to  inquire  of  the  patient  as  to  the 
condition  of  the  vision  before  the  cataract  appeared  and  if 
the  eye  were  injured. 

Treatment. — There  is  no  control  over  the  progress  of  lens 
opacities.  Massage  and  electricity  within  justifiable  limits  have 
no  appreciable  effect.  If  both  eyes  are  equally  advanced  and 
the  vision  considerably  reduced,  artificial  ripening  may  be 
resorted  to.  The  safest  method  consists  in  making  a  small 
opening  into  the  anterior  chamber  and  gently  stroking  the 
anterior  surface  of  the  lens  with  a  spatula  which  is  introduced 
through  the  opening.  Sometimes  an  iridectomy  (preliminary) 
will  hasten  the  ripening  process. 

If  a  senile  cataract  has  proved  suitable  for  operation  by 
the  method  of  examination  explained,  it  can  be  removed  only 
by  extraction,  which  is  performed  as  follows : 

Combined  and  Simple  Extraction. — The  skin  about  the  eye 
should  be  washed  with  soap  and  water,  and  the  lids,  especially 
at  the  roots  of  the  lashes,  thoroughly  cleansed.  Cocaine  hydro- 
chlorate  (4  per  cent.)  or  holocaine  hydrochloride  (1  per  cent.) 
is  instilled  two  or  three  times  at  intervals  of  five  minutes.  Be- 
fore beginning  the  operation,  the  eye  is  flushed  with  normal 
salt  solution,  bichloride  of  mercury  (1  :  5000),  or  boric  acid 
solution  (3  per  cent.).     The  patient  should  lie  on  the  back,  if 


94 


DISEASES  OF  THE  LENS. 


possible  in  bed,  and  the  daylight  or  artificial  illumination 
arranged  to  illuminate  the  eye  fully.  The  operator  should 
stand  back  of  the  patient's  head.     The  lids  are  kept  apart  by 


Fig.  20. 


Fixation  forceps. 


inserting  a  speculum,  and  the  conjunctiva  just  below  the  cornea 
is  firmly  seized  with  the  fixation  forceps  held  in  the  left  hand 
(when  operating  on  the  right  eye).  The  cataract  knife 
(Graefe),  with  the  edge  upward,  is  introduced  at  the  juncture 


Fjg.  21. 


Eye  speculum. 


of  the  cornea  and  the  sclera  on  the  temporal  side  a  little  above 
the  horizontal  meridian  of  the  cornea.  It  is  passed  across  the 
anterior  chamber  in  front  of  the  iris  and  pupil,  and  brought 
out  at  a  corresponding  point  on  the  opposite  side  (counter- 


FiG.  22. 


^^^=-C 


Cataract  knife. 


puncture).  As  soon  as  the  point  is  seen  outside  the  eye,  the 
knife  should  be  made  to  cut  upward  as  it  advances,  always 
keeping  the  incision  in  one  plane  at  the  sclerocorneal  junction. 


SENILE  CATARACT. 


95 


One  or  two  movements  of  the  knife  forward  and  backward 
will   finish  the  section.     Such  a  section  will  include  nearly 

Fig.  23. 


The  corneal  section  in  cataract  extraction.  Puncture  and  counterpuncture 
have  been  made.  The  section  will  pass  in  its  whole  extent  exactly  throus:h  the 
transparent  margin  of  the  cornea,  the  knife  remaining  in  the  same  plane  through- 
out.   Slightly  modified  from  de  Schweinitz.    (Ellett.) 

one-half  the  periphery  of  the  cornea,  but  should  be  somewhat 
smaller  if  an  iridectomy  is  to  be  made.  Some  operators  prefer 
to  finish  the  section  more  in  the  cornea  by  turning  the  blade 

Fig.  24. 


Iris  forceps. 
Fig.  25. 


Lens  scoop. 


forward  ;  others,  more  in  the  sclera,  forming  a  flap  of  conjunc- 
tiva, by  turning  the  knife  back  toward  the  equator  of  the  eye. 
The  next  step  (which  is  omitted  in  the  so-called  simple 
extraction)  is  the  iridectomy.  While  an  assistant  holds  the 
fixation  forceps,  the  operator,  entering  through  the  wound 


96  DISEASES  OF  THE  LENS. 

with  closed  ms  forceps,  seizes  the  iris  near  the  pupillary  edge 
and  pulls  it  out  through  the  wound.  A  piece  is  then  cut  off 
with  the  scissors,  close  to  the  eye.  When  the  iridectomy  is 
performed,  the  operation  is  called  the  combined  method. 

The  next  step  (which  follows  the  section  in  the  simple  ope- 
ration) is  the  capsulotomy.  The  capsulotome  is  entered  from 
the  temporal  side,  and  the  capsule  is  opened  by  a  number  of 
scratches  either  in  the  pupillary  area  or  above  the  edge  of  the 
pupil  under  the  iris.  If  properly  done,  the  lens  will  be  seen 
to  come  forward  toward  the  cornea.  The  fixation  forceps  is 
then  carefully  removed  and,  with  a  spoon,  pressure  is  made 
at  the  lower  edge  of  the  cornea  toward  the  centre  of  the  eye- 
ball. If  the  force  is  gradually  increased,  the  lens  will  enter 
and  open  the  wound,  slowly  dilating  the  pupil,  and  will  be 
delivered.  When  the  equator  of  the  lens  has  passed  the 
wound,  the  pressure  should  be  somewhat  relaxed  and  the 
spoon  should  be  passed  over  the  cornea,  following  the  lens 
out.  The  speculum  is  then  carefully  removed.  Some  ope- 
rators prefer  to  remove  the  speculum  and  extract  the  lens  by 
pressing  the  lower  lid  against  the  eyeball  at  the  lower  edge 
of  the  cornea.  Cortical  matter  remaining  behind  should  be 
worked  out  by  using  the  lower  lid  against  the  cornea.  The 
pupil  should  be  made  round  with  a  spatula  by  freeing  the 
iris  from  the  wound,  and  the  spatula  should  be  passed  along 
the  edge  of  the  wound  to  assure  proper  apposition.  If  an 
iridectomy  has  been  made,  the  cut  edges  of  the  iris  must  be 
freed  from  the  wound.  A  light  bandage  is  placed  over  both 
eyes  and  the  patient  kept  absolutely  quiet  on  the  back  in  bed. 
No  injury  should  be  allowed  to  happen  to  the  eye  by  any 
movement  of  the  head  or  hands.  On  the  following  day  it  is 
customary  to  inspect  the  eye,  and  if,  in  case  of  simple  extrac- 
tion, the  iris  is  found  caught  in  the  wound  (prolapse),  it 
should  be  drawn  out  with  the  iris  forceps  and  cut  off.  A 
drop  of  atropine  (1  per  cent.)  should  be  instilled  at  each  daily 
dressing.  Bandages  may  be  left  oif  the  other  eye  in  four  or 
five  days,  and  from  the  one  operated  on  about  the  seventh 
day.  The  patients  are  not  allowed  to  leave  the  hospital 
before  two  weeks. 


SENILE  CATARACT.  97 

Accidents  and  complications  liable  to  occur  are  improper 
place  and  size  of  the  incision,  difficult  delivery  due  to  adhe- 
sive lens,  small  incision,  or  imperfect  opening  of  the  capsule. 
There  may  he  rupture  of  the  suspensory  ligament  and  pro- 
lapse of  vitreous  due  to  too  large  incision,  too  much  pressure, 
patient  squeezing  the  lids,  or  to  frail  suspensory  ligament. 
In  the  after-treatment  there  may  occur  striated  keratitis 
(usually  harmless),  prolapse  of  iris,  iritis  beginning  generally 
after  the  third  day,  iridocyclitis  resulting  in  destruction  of  the 
eye,  suppuration  of  the  wound,  intraocular  hemorrhage,  or 
injury  from  hitting  the  eye. 

After- cataract. — The  capsule  out  of  which  the  lens  is  taken 
in  many  cases  is  left  as  a  more  or  less  opaque  membrane 
aci'oss  the  pupil  (secondary  cataract).  At  any  time  after  the 
eye  has  become  free  from  congestion  or  irritation  this  may  be 
cut  with  a  knife-needle  (discission-knife)  by  making  a  large 
crucial  incision.  Two  needles  entered  on  opposite  sides  of 
the  cornea  are  sometimes  employed.  If  there  are  tough  bands, 
they  may  be  cut  with  small  scissors,  as  those  of  de  W'^ecker. 
Glaucoma  rarely  occurs  after  these  operations.  The  loss  of 
the  refracting  power  of  the  eye  by  removing  the  lens — a  con- 
dition known  as  aphakia — must  be  made  good  by  wearing  a 
strong  convex  lens  (cataract  glass)  in  order  to  obtain  the  best 
vision.  Usually  about  +10  D.  is  required.  Often  some  astig- 
matism is  also  present. 

Traumatic  Cataract. — If  the  lens  capsule  is  opened,  the 
aqueous  enters  and  produces  swelling  and  opacity  of  the  lens. 
Traumatic  cataract  may  also  occur  from  contusion  without 
perforating  injury.  In  this  case  the  suspensory  ligament  is 
generally  ruptured,  or,  in  rare  cases,  the  capsule.  Rupture 
of  the  capsule  in  a  patient  under  thirty-five  may  be  followed 
by  gradual  and  complete  absorption  of  the  cataract.  In 
injured  and  diseased  eyes  the  lens  may  calcify. 

Treatment. — Traumatic  cataracts  should  be  treated  accord- 
ing to  the  principles  already  laid  down,  by  absorption  or  ex- 
traction, depending  upon  the  age  of  the  patient. 

7— E.  E. 


98  DISEASES  OF  THE  LENS 

DISLOCATION  OF  THE  LENS. 

Definition. — The  lens  may  be  displaced  partially  (sublux- 
ation) or  completely  (luxation)  from  its  position  behind  the 
iris  by  rupture  of  the  suspensory  ligament,  by  which  it  is 
attached  in  its  capsule  at  its  equator  to  the  ciliary  body  and 
ciliary  processes. 

Etiology. — Congenital,  secondary  to  pathologic  changes,  or 
traumatic. 

I.  Dislocation  may  be  backward,  upward,  downward,  or  to 
the  side  in  the  vitreous  chamber.  The  displaced  edge  may  often 
be  seen  with  the  ophthalmoscope  as  a  curved  black  line  in  the 
pupil.  Every  movement  of  the  eye  will  shake  the  lens  and 
the  iris  will  tremble  (iridodonesis  or  tremulous  iris). 

II.  The  lens  may  be  dislocated  partly  through  the  pupil  or 
entirely  into  the  anterior  chamber.  In  the  latter  case,  when 
it  is  clear  it  is  difficult  to  see.     Glaucoma  usually  supervenes. 

III.  The  lens  may  be  dislocated  through  a  wound  in  the 
sclera,  and  lie  under  the  conjunctiva.  A  dislocated  lens  is 
likely  to  become  cataractous. 

Treatment. — If  inflammation  or  glaucoma  occur,  the  lens 
should  be  removed  after  the  usual  cataract  incision,  either  by 
the  use  of  a  fenestrated  spoon  or  by  pressure. 

CONGENITAL  AFFECTIONS. 

Beside  those  mentioned  the  following  occur : 
^  Lenticonus  Posterior. — A  rare  congenital  affection   con- 
sisting of  a  bulging  of  the  centre  of  the  posterior  surface  of 
the  lens.     Lenticonus  anterior  is  extremely  rare. 

Coloboma  is  a  rare  condition,  in  which  part  of  the  lens  is 
absent. 

QUESTIONS. 

Define  and  give  classification  of  cataract. 
Explain  anterior  and  posterior  cataract. 
Define  and  give  rules  for  the  treatment  of  zonular  cataract. 
What  are  the  etiology  and  pathology  of  senile  cataract? 
Describe  four  stages  in  the  development  of  senile  cataract. 
Describe  the  examination  of  the  eye  for  the  determination  of  fitness  for 
operation. 


DISEASES  OF  THE   VITREOUS.  99 


What  is  artificial  ripening  ? 

Describe  the  operation  for  extraction  of  cataract. 

What  is  an  after-cataract  ? 

Describe  traumatic  cataract. 

In  what  directions  may  the  lens  be  dislocated? 

Mention  congenital  afiections  of  the  lens. 


CHAPTER   XI. 

DISEASES  OF  THE  VITREOUS. 

The  vitreous  humor  should  be  perfectly  clear  to  all  objec- 
tive methods  of  examination,  but  subjectively  floating  opaci- 
ties (muscae  volitantes)  may  always  be  seen  if  properly  searched 
for.  They  are  the  source  of  considerable  annoyance  to  ner- 
vous individuals.  They  are  shadows  thrown  on  the  retina  by 
the  vitreous  cells. 

OPACITIES  OF  THE  VITREOUS. 

Opacities  vary  in  form,  character,  and  origin.  They  inter- 
fere more  or  less  with  vision.  They  may  be  either  fixed  or 
floating.  In  the  latter  case  the  vitreous  is  fluid  in  consist- 
ence (synchysis) .  The  ophthalmoscope  is  used  in  the  exami- 
nation of  the  vitreous. 

Fixed  Opacities. — One  is  the  remains  of  the  hyaloid  artery 
in  the  canal  of  Cloquet.  This  appears  as  a  band  extending 
at  varying  distances  from  the  optic  nerve  into  the  vitreous, 
even  to  the  posterior  capsule  of  the  lens.  Other  fixed  opaci- 
ties are  bands  or  membranes  of  connective  tissue,  which  may 
be  congenital  or  the  result  of  organization  of  inflammatory 
exudate. 

Floating  opacities  may  be  dust-like  and  fill  the  whole 
vitreous  (characteristic  of  syphilis),  or  large  masses,  bands  or 
membranes  secondary  to  inflammation  of  the  ciliary  body, 
choroid,  or  retina,  to  hemorrhage,  injury,  or  to  degeneration  of 
the  vitreous.  Degenerative  changes  occur  in  high  myopia, 
old  age,  exhaustion  from  depressing  disease,  menstrual  dis- 
orders, systemic  disturbances,  or  may  be  idiopathic. 


100  DISEASES  OF  THE   VITREOUS. 

Synchysis  scintillans  is  a  peculiar  condition  in  which  the 
vitreous  is  filled  with  numerous  scales  which  reflect  the  light 
as  brilliant  floating  spots.     These  are  cholesterin  crystals. 

Treatment. — If  any  constitutional  disease  may  be  made  out, 
it  should  be  treated.  If  the  cause  of  the  vitreous  opacities 
is  inflammation  in  the  adjacent  tissues,  attention  should  be 
given  to  this. 

SUPPURATIVE  INFLAMMATION  OF  THE  VITREOUS. 

Synonym. — Purulent  hyalitis. 

Etiology. — Pus  in  the  vitreous  may  be  due  to  infection  from 
perforating  wounds,  or  may  be  of  metastatic  origin  from  men- 
ingitis, infectious  diseases,  or  from  ear  or  nose.  It  may  follow 
inflammations  of  the  uveal  tract,  or  occur  spontaneously  in 
debilitating  diseases. 

Symptoms. — The  cornea,  aqueous,  and  lens  are  clear,  but  a 
yellow  reflex  is  obtained  back  of  the  lens.  A  few  pos- 
terior synechise  may  be  found.  If  the  disease  is  advanced, 
the  eye  will  be  soft  and  the  periphery  of  the  iris  will  be 
drawn  back  by  traction  on  the  ciliary  processes  from  within. 
Such  a  condition  may  be  mistaken  for  glioma  of  the  retina, 
and  is  sometimes  called  pseudoglioma  (see  Glioma  of 
the  Retina).  When  the  process  is  acute  and  severe,  it  is 
known  as  panophthalmitis,  or  abscess  of  the  eye,  in  which  case 
the  w^hole  eye  and  surrounding  orbital  tissue  are  involved. 

Treatment. — If  the  inflammatory  conditions  subside,  it  is 
not  necessary  to  perform  enucleation  for  pseudoglioma.  In 
panophthalmitis,  hot  fomentations  and  incision  into  the  eye 
to  evacuate  pus  are  indicated.  Enucleation  has  been  followed 
by  meningitis. 

QUESTIONS. 

What  are  miiscfe  volitantes  ? 

What  are  the  forms  of  opacities  of  the  vitreous  ? 

Define  synchysis  scintillans. 

Describe  suppuration  of  the  vitreous  and  give  treatment. 

What  is  pseudoglioma  ? 


DISEASES  OF  THE  RETINA,  101 

CHAPTER  XII. 

DISEASES  OF  THE  RETINA. 

Andemia  and  Hyperaemia  of  the  retina  occasionally  occur 
as  the  result  of  local  or  general  conditions,  but  the  varia- 
tions may  be  considerable  within  physiologic  limits. 

Retinitis. — Simple,  albuminuric,  syphilitic,  and  pigmented 
varieties  of  retinitis  occur. 

Eetinitis  is  often  associated  with  choroiditis  (chororetinitis) 
or  with  inflammation  of  the  optic  nerve  (neuroretinitis). 

SIMPLE   RETINITIS. 

Etiology. — The  causes  are  often  obscure.  There  is  com- 
monly some  constitutional  disturbance — e.  g.,  arteriosclerosis, 
anaemia,  leukaemia,  malaria,  etc.  Cases  may  be  due  to  albu- 
minuria, syphilis,  or  diabetes;  but  such  causes  generally  pro- 
duce eiiaracteristic  appearances,  which  will  be  described  under 
S(^parate  heads. 

Subjective  Symptoms. — The  patient  complains  of  impaired 
vision  and  blurs  in  the  field  of  vision  and  flashes  of  light. 
There  may  be  photophobia  and  distortion  of  objects  (meta- 
morphopsia). 

Objective  Symptoms. — There  may  be  found  only  slight  dis- 
turbance of  the  retina,  such  as  dilated  veins,  tortuous  vessels, 
and  a  few  hemorrhages ;  or,  in  more  marked  cases,  a  cloudy 
fundus,  dilated  and  distorted  vessels  buried  in  the  swollen 
retina,  with  numerous  flame-like  hemorrhages,  and  the  out- 
line of  the  nerve  is  blurred.  The  disease  may  be  unilateral 
or  bilateral.     The  duration  is  usually  several  months. 

Treatment. — The  eyes  should  be  protected  from  light  and 
strain.  Mercury,  or  potassium  iodide,  sodium  salicylate,  and 
diaphoretics  may  be  given. 

Hemorrhagic  Retinitis. — A  form  of  simple  retinitis  in 
Avhich  hemorrhages  are  the  most  striking  feature.  It  is  most 
common  in  elderly  people  with  apoplectic  tendencies  du^  t9 


102 


DISEASES  OF  THE  RETINA. 


arteriosclerosis.  Thrombosis  of  the  retinal  veins  may  occasion 
hemorrhages  with  dilated  veins.  At  times  hemorrhage  occurs 
between  the  retina  and  vitreous  (subhyaloid). 

ALBUMINURIC  RETINITIS. 

Definition. — A  distinct  type  of  retinitis  accompanying  acute 
or  advanced  chronic  nephritis.     Usually  bilateral. 

Etiology. — The  cause  is  nephritis,  usually  chronic  inter- 
stitial.    It  also  occurs  in  Bright's  disease  of  pregnancy  and 

Fig.  26. 


Albuminuric   retinitis.    Granular   kidney.     Note   hard-edged  "asterisk"  exuda- 
tion at  macula,  and  the  punctate  and  linear  hemorrhages,    (Posey  and  Wright.) 

in  acute  nephritis.     Diabetes  is  the  cause  of  a  somewhat  simi- 
lar condition  in  the  retina. 

The  only  subjective  s3anptom  is  interference  with  vision. 
This  is  sometimes  surprisingly  slight  in  cases  showing  marked 


RETINITIS  PIGMENTOSA.  103 

fundus  changes.  Patients  with  nephritis  are  subject  to  attacks 
of  temporary  blinchiess  of  uraemic  origin,  with  or  without 
retinitis.  By  ophthalmoscopy  there  may  appear  the  signs  of 
simple  retinitis — swelling,  tortuous  vessels,  Fiemorrhages,  and, 
in  addition,  shining  white  patches  scattered  through  the 
fundus,  and  a  peculiar  arrangement  of  glistening  white  dots 
around  the  macula.  This  is  a  stellate  figure  formed  by  radi- 
ating lines. 

Pathology. — The  white  patches  are  due  to  fatty  degeneration 
of  the  retinal  elements  and  to  exudate. 

Prognosis. — Retinitis  in  chronic  nephritis  is  a  late  mani- 
festation, and  the  patient  is  not  likely  to  live  more  than  two 
years  after  the  appearance  of  the  eye  lesion.  Temporary  im- 
])rovcment  may  occur,  especially  when  the  disease  assumes  an 
acute  or  inflammatory  exudative  form. 

Treatment. — No  local  treatment  is  of  use.  When  the  dis- 
ease appears  in  ^  pregnancy,  the  question  of  producing  prema- 
ture labor  is  a  grave  one.  If  the  retinitis  is  marked  and 
occurs  before  the  seventh  month,  it  may  be  wise  to  induce 
labor.  If  after  the  seventh  month,  and  mild,  it  is  better  to 
wait. 

SYPHILITIC  RETINITIS. 

Etiology. — Occurs  in  the  second  stage  of  acquired  syphilis 
and  in  the  congenital  form. 

Subjective  symptoms  are  the  same  as  for  other  forms  of  retinitis. 

Objective  Symptoms. — The  ophthalmoscope  shows  dust-like 
opacities  in  the  vitreous — a  pecnliar  bluish-gray  haze  over 
the  retina,  about  the  disk  and  macula,  and  streaks  of  white 
exudate  along  the  vessels. 

Course. — The  course  is  chronic,  leading  to  choroiditis  and 
atrophy  of  the  optic  nerve. 

Treatment. — Antisyphilitic.  Should  be  energetic,  and  if 
begun  early  may  be  successful. 

RETINITIS  PIGMENTOSA. 

Definition. — A  disease  chamcterized  by  a  prolonged  course, 
beginning  in  youth  and  prolonged  for  ^ears.     There  is  loss 


104  DISEASES  OF  THE  RETINA. 

of  vision,  especially  in  subdued  light,  as  in  the  twilight  or 
evening  (night  blindness,  nyctalopia).  There  is  a  peculiar 
arrangement  of  the  retinal  pigment  into  masses  of  irregular 
shape,  mostly  with  branching  projections.  These  appear  first 
at  the  periphery,  later  approach  the  nerve.  The  field  of 
vision  becomes  gradually  narrowed.  The  nerve  and  retina 
become  atrophic,  and  the  bloodvessels  of  the  retina  much 
reduced  in  calibre.  There  is  a  strong  hereditary  tendency, 
and  consanguinity  in  parents  is  an  element. 

EMBOLISM  OF  THE  CENTRAL  ARTERY  OF  THE  RETINA. 

Definition. — Plugging  of  the  central  artery,  or  more  rarely 
a  single  branch. 

Etiology. — There  may  be  heart  lesion  or  obliterating  endarte- 
ritis of  the  retinal  vessels. 

Symptoms. — There  is  sudden  blindness  in  one  eye  without 
pain  or  other  symptoms.  The  retina  in  a  short  time  begins  to 
assume  a  foggy  appearance  (oedema),  especially  near  the  centre 
of  the  fundus.  A  cherry-red  spot  is  found  at  the  macula. 
The  arteries  are  small  and  the  veins  contain  little  blood. 
Later  the  circulation  may  be  restored,  the  blood  returning  at 
times  in  broken  columns.  Atrophy  of  the  retina  and  nerve 
usually  results.  Occasionally  central  vision  is  preserved,  which 
is  due  to  the  existence  of  a  branch  of  the  central  artery  com- 
ing off  back  of  the  location  of  the  embolus  (or  of  a  branch 
from  the  ciliary  arteries),  supplying  the  macular  region. 

Treatment. — Massage  is  recommended. 

DETACHMENT  OF  THE  RETINA. 

Synonym. — Ablatio  retinae. 

Definition. — Separation  of  the  retina  from  the  choroid, 
leaving  behind  the  layer  of  retinal  pigment. 

Etiology. — This  may  occur  from  the  extravasation  of  blood 
or  serum,  or  from  the  presence  of  exudate  or  new  growth.  It 
may  also  occur  from  the  traction  of  bands  of  connective  tissue 
in  the  vitreous,    The  ordinary  form  occurs  as  a  complication 


DETACHMENT  OF  THE  RETINA.  105 

of  myopia  of  high  degree.     Traumatism  is  the  next  most  fre- 
quent cause. 

Symptoms. — The  patient  complains  of  poor  vision  and  de- 
fect in  the  field  of  vision  corresponding  to  the  detachment. 
The  ophthalmoscope  often  reveals  floating  opacities  in  the 
vitreous.  The  detached  retina  appears  as  a  wavy  grayish  or 
greenish-white  membrane,  over  which  the  very  dark-red 
retinal   bloodvessels   run    in   tortuous   course.      The    retina 

Fig.  27. 


Detachment  of  the  retina.    (Jaeger.) 

usually  floats  about  with  the  movements  of  the  eye.  A  tear 
is  sometimes  seen.     The  tension  of  the  eye  is  reduced. 

Prognosis. — These  cases,  especially  if  complicating  myopia, 
get  worse,  and  all  vision  is  lost.  The  cases  occurring  as  the 
result  of  traumatism  are  the  most  favorable,  but  the  prognosis 
is  always  bad. 

Treatment. — In  recent  cases  rest  in  bed  for  a  number  of 
weeks  should  be  ordered ;  also  hypodermatic  injections  of 


106  DISEASES  OF  THE  RETINA. 

pilocarpine  (gr.  -^^  to  produce  sweating,  every  day  or  two. 
Puncture  of  the  sclera  over  the  detachment  and  subconjunc- 
tival injections  are  of  questionable  value. 

GLIOMA  OF  THE  RETINA. 

Definition. — A  malignant  intraocular  tumor  occurring  in 
early  childhood  or  infancy,  commonly  before  three  years  of  age. 

Pathology. — Glioma  springs  from  the  granular  layer  of  the 
retina,  grows  underneath  the  retina  (exophytum),  or  on  top 
of  it  in  the  vitreous  (endophytum).  It  consists  of  blood- 
vessels, small  round  cells,  and  cells  with  protoplasmic  proc- 
esses in  scant  stroma. 

Symptoms. — In  the  first  stage  there  appears  a  shining  white 
or  yellowish  reflex  from  the  interior  of  the  eye  (formerly 
called  "amaurotic  cat's  eye").  The  eye  is  blind.  A  few 
bloodvessels  may  be  seen  on  the  mass  in  the  vitreous.  In 
the  second  stage  (glaucomatous)  the  eye  becomes  hard  by  the 
growth  of  the  tumor  filling  the  interior.  It  is  ])ainful  and 
somewhat  congested.  Third  stage.  The  new  growth  bursts 
through  the  eye  and  extends  either  backward  into  the  orbit 
or  forward  toward  the  outside.  Fourth  stage.  Metastatic 
growths  appear  in  other  organs.  The  otlier  eye  may  be 
affected,  and  the  child  dies  of  cerebral  complications  or  from 
exhaustion.  Other  children  in  the  same  family  are  sometimes 
affected. 

Differential  Diagnosis. — The  condition  may  be  mistaken  for 
purulent  choroiditis  (pseudoglioma). 

Glioma  occurs  in  early  childhood,  with  no  history  of  injury 
or  meningitis.  Tumor  often  well  defined,  with  rest  of  vitreous 
clear.     Anterior  chamber  shallow  and  tension  increased. 

Pseudoglioma  may  occur  at  any  age  ;  follows  injury  or  men- 
ingitis. Vitreous  immediately  and  wholly  filled  with  yellow- 
ish mass.  Inflammatory  signs  appear  early.  The  iris  is 
bulging  at  the  pupillary  edge,  but  retracted  at  the  periphery. 
Tension  is  minus. 

Treatment. — The  eye  should  be  enucleated  at  the  earliest 
jTioipent, 


BARER  FORiMS  OF  RETINAL  DISEASE.  107 

OPAQUE  NERVE-FIBRES. 

Definition. — A  congenital  anomaly  showing  flame-like,  glis- 
tening, white  patches  extending  from  the  optic  nerve  into  the 
retina.  They  are  formed  of  nerve-fibres  which  have  re- 
tained their  medullary  sheaths,  normally  lost  as  the  fibres 
pass  through  the  lamina  cribrosa  into  the  eye. 

INJURIES  OF  THE  RETINA. 

Beside  the  diseases  already  mentioned  as  due  to  traumatism, 
contusions  and  wounds  may  occur.  Commotio  retinae  (oedema 
of  the  retina)  arises  from  contusions  and  shows  defective 
vision  and  gray  infiltration  of  the  retina,  especially  in  the 
macular  region. 

RARER  FORMS  OF  RETINAL  DISEASE. 

Retinitis  Proliferans. — Characterized  by  masses  of  con- 
nective tissue  in  the  vitreous,  which  contain  bloodvessels. 
Hemorrhages  are  undoubtedly  the  original  lesion. 

Retinitis  Circinata. — Presenting  a  white  circle  of  exudate 
concentric  with  the  macula. 

Retinitis  Striata. — Showing  white  streaks  of  fibrous  tissue 
in  the  retina. 

Angioid  Streaks. — Black  or  brown  striae,  in  deeper  layer ; 
probably  due  to  hemorrhages. 

Snow  Blindness. — From  exposure  to  brilliant  light,  such 
as  from  snow  or  electric  light.  There  may  be  central  sco- 
toma, macular  changes,  and  retinitis. 

Amaurotic  Family  Idiocy. — Symmetric  changes  at  the 
macula  in  infancy.  A  peculiar  condition,  showing  a  hazy 
area  in  the  macular  region,  with  a  red  spot  in  the  centre.  The 
disease  is  probably  due  to  degeneration  of  ganglion-cells  of 
the  retina,  following  arrest  of  development  of  the  nervous 
system.  There  is  a  strong  hereditary  influence.  Jews  are 
more  prone  to  the  disease  (Jacobi).  The  children  all  die  within 
a  year  or  two, 


108  DISEASES  OF  THE  RETINA. 

AMBLYOPIA  OR  FUNCTIONAL  DISEASE  OF  THE  RETINA. 

In  the  ordinary  acceptance  of  the  term  amblyopia  is  used 
to  signify  a  defect  in  vision  without  discoverable  lesion  or 
refractive  error.  Amaurosis  is  a  name  which  has  fallen  into 
disuse,  but  signifies  total  blindness  from  unknown  causes. 

The  forms  of  amblyopia  are  (I.)  congenital,  (II.)  hysterical, 
(III.)  simulated,  and  (lY.)  toxic. 

I.  Congenital  Amblyopia.— Commonly  associated  with 
errors  of  refraction,  especially  hypermetropia  and  astigma- 
tism. In  convergent  strabismus  the  squinting  eye  is  likely 
to  be  amblyopic.  It  is  commonly  believed  that  this  is  from 
nonuse  (amblyopia  ex  anopsia). 

II.  Hysterical  Amblyopia.— Generally  unilateral.  Blind- 
ness may  be  partial  or  total.  The  field  of  vision  is  con- 
tracted, especially  after  repeated  examinations.  The  fields 
for  colors  are  reversed  as  to  their  order  in  point  of  size. 

III.  Simulated  Amblyopia.— Malingering  is  not  unknown, 
and  is  attempted  for  various  reasons.  Generally  blindness 
in  one  eye  only  is  feigned.  When  a  prism  is  placed  over  one 
eye,  such  patients  will  often  acknowledge  diplopia,  and  will 
find  difficulty  in  walking,  etc. 

IV.  Toxic  Amblyopia. — Under  this  head  may  be  classed 
amblyopia  occurring  in  uraemia,  malaria,  and  poisoning  with 
drugs,  such  as  quinine,  tobacco,  and  alcohol.  Lesions,  espe- 
cially of  the  nerve,  are  often  developed. 

QUESTIONS. 

Mention  the  varieties  of  retinitis. 

Give  the  etiology,  symptoms,  and  treatment  of  simple  retinitis. 

What  is  albuminuric  retinitis  ?  Give  the  etiology,  symptoms,  pathology, 
prognosis,  and  treatment. 

Describe  syphilitic  retinitis. 

Define  retinitis  pigmentosa. 

Explain  embolism  of  the  central  artery  of  the  retina. 

Give  the  etiology,  symptoms,  prognosis,  and  treatment  of  detachment  of 
the  retina. 

Give  the  four  stages  of  glioma  of  the  retina. 

Give  the  differential  diagnosis  between  glioma  and  pseudoglioma. 

What  are  opaque  nerve-fibres? 

What  diseases  may  be  produced  by  traumatism  ? 

What  constitutional  diseases  produce  afiections  of  the  retill^? 

P^scnbe  the  four  forms  of  amblyopia. 


DISEASES  OF  THE  CHOROID.  109 

CHAPTER  XIII. 
DISEASES   OF  THE  CHOROID. 

The  choroid  is  the  vascular  tunic  of  the  eye  and  liable  to 
inflammation.  Its  intimate  connection  with  the  retina  makes 
their  simultaneous  involvement  of  common  occurrence, 
although  the  entirely  separate  blood-supply  renders  disease 
of  each  distinctive. 

Varieties. — Exudative  choroiditis,  serous  choroiditis,  sup- 
purative choroiditis,  and  sclerochoroiditis  posterior. 

EXUDATIVE  CHOROIDITIS. 

Definition. — A  disease  characterized  by  localized  patches  of 
plastic  inflammation,  later  producing  atrophic  areas. 

Pathology. — The  exudate  is  a  collection  of  round  cells  in 
the  choroid  and  in  the  outer  layers  of  the  retina.  Organi- 
zation of  this  exudate  causes  atrophy  and  disturbance  in  the 
pigment. 

Etiology. — Syphilis  (congenital  or  acquired)  is  the  most 
common  cause,  also  general  disorders  of  nutrition,  and  it 
may  be  idiopathic.     Tuberculous  deposits  occur  very  rarely. 

Varieties. — Central,  Occurs  not  infrequently  in  myopia, 
syphilis,  and  in  elderly  persons  as  a  senile  change.  Dissemi- 
nate. Essentially  chronic,  characterized  by  scattered  patches. 
Diffuse.  Always  accompanied  by  involvement  of  the  retina 
and  called  chorioretinitis.  Due  to  syphilis.  Isolated.  Some 
cases  are  characterized  by  isolated  patches  of  exudate  occurring 
in  people  as  result  of  overexertion  or  idiopathic.  Not  due  to 
syphilis.     Runs  a  comparatively  short  course. 

Symptoms. — Gradual  loss  of  sight  is  complained  of,  although 
the  vision  is  sometimes  good,  with  extensive  changes.  The 
field  of  vision  may  be  contracted,  and  there  may  be  scotomata. 
When  recent,  the  diseased  areas  appear  as  irregular  hazy, 
white  or  yellowish  patches.  Isolated  hemorrhages  may  occur. 
In  the  stage  of  atrophy  there  are  masses  of  pigment  or  white 
patches  with  or  without  rings  of  pigment  about  them.     Opaci- 


110  DISEASES  OF  THE  CHOROID, 

ties  of  the  vitreous  and  lens  or  atrophy  of  the  optic  nerve 
may  complicate  the  case. 

Treatment. — Mercury,  either  internally  or  by  inunctions,  is 
beneficial  even  in  nonspecific  cases.  Iodide  of  potassium  in 
full  doses  or  large  doses  of  salicylate  of  sodium  are  of  value. 

Serous  Choroiditis.     (See  Serous  Iritis.) 

SUPPURATIVE  CHOROIDITIS. 

Definition. — This  condition  is  practically  the  same  as  de- 
scribed under  suppurative  inflammation  of  the  vitreous.  On 
rare  occasions  in  the  course  of  infectious  or  wasting  diseases 
the  beginning  of  the  suppurative  process  may  be  seen  as  foci 
of  infection  in  the  choroid.  These  quickly  involve  the  whole 
interior  of  the  eye  in  purulent  inflammation. 

Treatment. — Unless  the  case  may  be  aborted,  which  is  prac- 
tically impossible,  the  eye  is  lost. 

SCLEROCHOROIDITIS  POSTERIOR. 

Definition. — Consists  in  a  slow  process  of  atrophy  of  the 
choroid  surrounding  the  optic  nerve,  especially  on  the  side 
toward  the  macula.  It  complicates  myopia,  and  is  associated 
with  bulging  of  the  sclera  in  this  place  (posterior  staphyloma). 
See  page  132. 

TUMORS  OF  THE  CHOROID. 

Sarcoma,  gumma,  tubercle,  and  secondary  carcinoma  are  of 
rare  occurrence. 

SARCOMA  OF  THE  CHOROID. 

Pathology. — Melanosarcoma  is  the  most  common  form. 

Symptoms. — First  Stage. — The  patient  complains  of  blurred 
vision.  A  tumor  will  be  seen  in  some  part  of  the  fundus. 
Over  it  other  vessels  beside  those  of  the  retina  will  be  seen. 
The  retina  is  often  detached  on  one  side. 

Second  Stage. — The  eyeball  becomes  hard  and  painful,  and 
the  vision  is  lost. 


QUESTIONS.  Ill 

Third  Stage. — The  tumor  involves  the  surrounding  parts. 
It  ruptures  through  the  globe  or  extends  backward  through 
the  optic  nerve. 

Fourth  Stage. — Metastatic  growths  appear. 

Diagnosis. — A  tumor  showing  vessels  beside  those  of  the 
retina,  with  increase  of  tension. 

Prognosis. — Unless  seen  in  the  early  stage,  the  prognosis  is 
decidedly  bad. 

Treatment. — Immediate  enucleation,  with  the  optic  nerve 
cut  well  back. 

INJURIES  OF  THE  CHOROID. 

Beside  the  direct  laceration  of  the  choroid  in  perforating 
injuries,  it  may  be  ruptured  by  contusions.  Such  a  condition 
shows  a  curved  white  line  of  exposed  sclera  bordered  with 
pigment  usually  concentric  with  the  optic  nerve. 

Treatment. — None  is  possible. 

CHOROIDAL   HEMORRHAGE. 

Choroidal  hemorrhage  may  occur  from  injury  or  from 
sudden  relief  of  pressure  in  operations  which  open  the  eye- 
ball. 

CONGENITAL  DEFECTS  OF  THE  CHOROID. 

Goloboma  is  a  defect  in  development  owing  to  imperfect 
closure  of  the  foetal  cleft.  It  appears  as  a  white  area  of  ex- 
posed sclera,  stretching  usually  from  the  optic  nerve  toward 
the  ciliary  body  and  iris,  which  may  be  involved  in  the  same 
way.  There  are  often  irregularities  in  the  surface  of  the  area, 
wliich  is  bordered  with  more  or  less  pigment.  An  uncommon 
form  of  coloboma  is  confined  to  the  macula. 

Albinism  of  the  eye  is  a  condition  of  absence  of  pigment. 

QUESTIONS. 

Name  the  varieties  of  choroiditis. 
Name  the  varieties  of  exudative  choroiditis. 
Describe  four  stages  of  sarcoma  of  the  choroid. 
Describe  rupture  of  the  choroid  and  congenital  defects. 


112  DISEASES  OF  THE  OPTIC  NEHVE. 

CHAPTER  Xiy. 

DISEASES  OF  THE  OPTIC    NERVE. 

The  diagnosis  of  ansemia  or  liyperaemia  of  the  optic  nerve 
should  be  made  with  care,  in  view  of  variations  within  pliysio- 
logic  limits.  If  the  optic  nerve  is  inflamed  at  its  entrance 
into  the  eye,  the  condition  is  called  optic  neuritis,  intraocu- 
lar neuritis,  or  papillitis.  If  the  process  is  confined  to  the 
nerve  behind  the  eyeball,  it  is  known  as  retrobulbar  neuritis. 

OPTIC  NEURITIS. 

Definition. — An  inflammation  of  the  head  of  the  optic  nerve, 
characterized  by  congestion  and  swelling  of  the  optic  disk. 

Etiology. — Papillitis  occurs  in  brain  tumors,  generally  in  the 
form  known  as  '^  choked  disk.^^     It  is  also  caused  by  syphilis, 

Fig.  28. 


Ophthalmoscopic  appearance  of  severe  recent  papillitis.    Several  elongated  patches 
of  blood  near  border  of  disk.    (After  Hughlings  Jackson.) 

nephritis,  rheumatism,  ansemia,  diseases  of  the  vascular  system, 
infectious  diseases,  and  poisons,  as  well  as  diseases  of  the  orbit 


ACUTE  RETROBULBAn  NEURITIS.  11^ 

and  adjacent  sinuses.  Tuberculous  and  other  forms  of  menin- 
gitis are  the  cause  of  descending  neurntis. 

Pathology. — There  is  infiltration  of  white  cells.  The  pa- 
thology of  "  choked  disk  '^  is  yet  unsettled,  but  this  condition 
seems  to  be  due  to  increased  intracranial  pressure,  with  disten- 
tion of  the  optic  nerve  sheath. 

Subjective  Symptoms. — The  patient  complains  of  defective 
vision,  which  is,  however,  independent  of  the  apparent  sever- 
ity of  the  lesion,  for  marked  cases  may  retain  excellent  vision. 

Objective  Symptoms. — There  are  no  external  signs.  With 
the  ophthalmoscope  the  optic  disk  is  congested  or  of  whitish 
color.  The  edges  are  blurred  and  streaked.  There  is  more 
or  less  swelling  of  the  disk.  The  veins  are  distended  and 
tortuous  and  the  arteries  small.  There  may  be  hemorrhages. 
The  field  of  vision  is  usually  defective.  The  neighboring 
retina  is  always  involved  to  some  extent,  but  there  may  be 
general  retinitis  (neuroretinitis).  The  disease  is  usually  bilat- 
eral. In  "  choked  disk  '^  there  is  great  swelling  of  the  nerve 
(oedema),  dilatation  of  vessels,  and  hemorrhages. 

Course. — The  disease  lasts  for  months.  The  inflammation 
may  subside  without  after-effects,  or  the  nerve  may  pass  into 
a  condition  of  atrophy  (postneuritic). 

Treatment. — The  treatment  consists  in  giving  attention  to 
the  cause,  sweating  with  pilocarpine,  potassium  iodide,  sodium 
salicylate,  and  rest  in  bed. 

ACUTE  RETROBULBAR  NEURITIS. 

Definition. — An  inflammation  of  the  orbital  portion  of  the 
optic  nerve. 

Etiology. — Syphilis,  rheumatism,  infectious  diseases,  pois- 
ons— e.  g.,  methyl  alcohol — and  secondary  to  inflammation  in 
the  adjacent  tissues. 

Pathology. — In  most  cases  the  inflammation  is  confined  to 
the  fibres  which  supply  the  macula. 

Symptoms. — Rapid  loss  of  sight,  orbital  pain  and  tender- 
ness. There  may  be  no  intraocular  evidence  of  disease  or 
only  appearances  of  moderate  optic  neuritis.     Optic   nerve 

8— E.  E. 


114  DISEASES  OF  THE  OPTIC  NERVE. 

atrophy,  especially  on  the  temporal  side  of  the  disk,  is  likely 
to  follow  with  central  scotoma. 

Treatment. — Same  as  for  optic  neuritis. 

CHRONIC  RETROBULBAR  NEURITIS. 

Synonym. — Toxic  amblyopia. 

Definition. — A  disease  characterized  by  gradual  loss  of 
vision  and  atrophy  of  the  optic  disk  on  the  temporal  side. 

Etiology. — Nicotine,  especially  combined  with  alcohol,  is  the 
most  common  cause.  Lead,  arsenic,  bisulphide  of  carbon,  and 
other  poisons  may  also  produce  it.  It  occurs  in  middle  and 
late  life. 

Pathology. — The  lesion  is  a  chronic  interstitial  inflammation 
of  the  macular  fibres  of  the  nerve,  which  occupy  the  temporal 
side  of  the  nerve  at  the  optic  disk,  but  pass  into  its  centre 
further  back  in  the  orbit. 

Symptoms. — The  patients  find  their  sight  gradually  failing. 
There  are  diminution  in  central  vision  (central  relative  sco- 
toma) and  defect  in  color  perception .  in  a  small  area  about 
the  fixation  point  (central  color  scotoma).  The  ophthalmo- 
scope shows  a  decided  pallor  of  the  disk  on  the  outer  side  and 
dilatation  of  the  retinal  veins.     The  disease  aff*ects  both  eyes. 

Course. — It  is  of  long  duration,  but  never  produces  total 
blindness. 

Treatment. — Alcohol  and  tobacco  should  be  absolutely  cut 
off.  Strychnine  may  be  given  to  the  physiologic  limit; 
also  potassium  iodide. 

ATROPHY  OF  THE  OPTIC  NERVE. 

Definition. — A  condition  of  the  optic  nerve  characterized 
by  degeneration  and  shrinking  of  its  fibres,  and  showing  a 
white  or  gray  disk. 

Etiology. — Atrophy  may  be :  a.  Primary,  idiopathic,  or 
associated  with  diseases  of  the  brain  or  spinal  cord.  There 
is  an  hereditary  type,  which  affects  members  of  the  same 
family.  It  begins  in  youth,  and  gradually  produces  total 
blindness,     b.  Secondary  to  optic  neuritis  or  diseases  of  the 


QUESTIONS.  115 

choroid  and  retina  and  glaucoma ;  also  after  injuries  and 
compression. 

Pathology. — There  is  chronic  interstitial  inflammation,  with 
atrophy  of  the  nerve-fibres. 

Symptoms. — The  patient  has  no  symptoms  except  gradual 
loss  of  sight  and  perhaps  contraction  of  the  field  of  vision. 
The  disk  varies  in  appearance  from  the  slightest  degree  of 
pallor  to  the  most  intense  white  or  gray.  In  advaruced  cases 
there  will  be  noticed  a  depression  in  the  centre  of  the  disk, 
Avith  sloping  sides.  The  edges  of  the  nerve  are  sharply  de- 
fined, except  when  following  optic  neuritis.  There  are  con- 
centric or  irregular  contraction  of  the  field  of  vision  and 
defects  in  color  perception. 

Course  is  usually  long. 

Treatment. — If  any  indications  for  general  treatment  can 
be  found,  they  should  be  followed.  Strychnine  in  full  doses, 
preferably  by  the  hypodermatic  method,  potassium  iodide, 
arsenic,  electricity,  and  massage,  may  be  tried,  but  are  of 
little  value. 

Tumors  of  the  Optic  Nerve. — Fibroma,  sarcoma,  endo- 
thelioma, myxoma,  tubercle,  and  glioma  are  known  to  occur. 
Hyaline  bodies  are  found  on  the  disk. 

CONGENITAL  AFFECTIONS. 

Inferior  Conus. — A  congenital,  white  crescent,  usually  on 
the  lower  side  of  the  nerve. 

Coloboma  of  Optic  Nerve-sheath  shows  a  depression  on 
the  lower  side  of  the  disk,  due  to  absence  of  the  sheath. 

QUESTIONS. 

state  the  two  forms  of  hiflammation  of  the  optic  nerve. 

Describe  acute  and  chronic  papillitis;  also  retrobulbar  neuritis. 

Give  the  etiology,  symptoms,  and  treatment  of  atrophy  of  the  optic  nerve. 

What  general  diseases  cause  affections  of  the  optic  nerve? 


116  DISEASES  OF  THE  DEBIT. 

CHAPTER  Xy. 

DISEASES   OF  THE  ORBIT. 

PERIOSTITIS. 

Etiology. — Occurs,  especially  at  the  margin,  from  trau- 
matism, syphilis,  rheumatism,  tuberculosis,  and  extension 
from  the  neighboring  sinuses. 

Symptoms  are  pain,  tenderness,  swelling,  and  perhaps  ab- 
scess, with  fistula  and  contracture,  later  producing  cicatricial 
ectropion. 

Treatment. — Constitutional,  hot  applications,  and  incision. 

ORBITAL  CELLULITIS. 

Definition. — Inflammation  of  the  cellular  tissue  of  the  orbit, 
usually  terminating  in  suppuration. 

Etiology. — Injuries,  erysipelas,  septicaemia,  extensions  from 
neighboring  sinuses,  and  idiopathic. 

Sympt^^ms. — There  may  be  constitutional  disturbance,  swell- 
ing of  the  lids,  chemosis,  exophthalmos,  and  perhaps  panoph- 
thalmitis and  meningitis. 

Treatment. — Hot  applications,  incision  into  the  orbit  if  pus 
has  formed. 

TUMORS  OF  THE  ORBIT. 

Cyst,  aneurism,  angioma,  osteoma,  sarcoma,  and  carcinoma 
have  been  reported. 

Treatment. — Excision,  with  preservation  of  the  eye  if  pos- 
sible. The  operation  of  Kronlein  (osteoplastic)  consists  in 
removing  part  of  the  outer  wall  of  the  orbit,  and  gives  access 
to  the  orbit.  The  whole  contents  of  the  orbit  are  some- 
times removed  in  case  of  malignant  disease  (exenteration). 

QUESTIONS. 

Describe  periostitis  and  orbital  cellulitis. 
Give  the  treatment  of  tumors  of  the  orbit. 


DISEASES  OF  THE  EYEBALL,  117 

CHAPTER  XVI. 
DISEASES   OF  THE  EYEBALL. 

EXOPHTHALMOS. 

Synonym. — Proptosis. 

Definition. — A  condition  in  which  the  eyeball  is  pushed 
forward  from  orbital  inflammation,  hemorrhage,  tumors,  or 
in  exophthalmic  goitre. 

PULSATING  EXOPHTHALMOS. 

Definition. — Protrusion,  with  pulsation  of  the  eyeball  and 
surrounding  parts.  A  bruit  is  heard  above  the  eye.  Gener- 
ally due  to  traumatism  causing  communication  iDetween  the 
carotid  artery  and  cavernous  sinus. 

Treatment. — Tying  the  common  carotid  artery. 

EXOPHTHALMIC  GOITRE. 

Synonyms. — Graves'  disease,  Basedow's  disease. 

Definition. — A  disease  of  the  nervous  system  in  which  the 
heart  action  is  accelerated,  thyroid  gland  enlarged,  and  the 
eyes  prominent. 

Subjective  and  Objective  Symptoms. — The  exophthalmos  is 
partly  only  apparent  on  account  of  the  widening  of  the  pal- 
pebral fissure  (Dalrymple's  symptom).  When  the  eyes  are 
turned  downward,  the  upper  lid  does  not  follow  (Graefe's 
symptom).  There  is  also  infrequent  winking  (Stellwag's 
symptom).  If  the  exophthalmos  is  extreme,  the  cornea 
suffers  from  exposure,  since  the  lids  can  not  be  closed. 

Treatment. — Beside  general  treatment,  thyroidectomy  and 
sympathectomy  have  been  tried. 

Enophthalmos  is  recession  of  the  eyeball  into  the  orbit. 
Usually  traumatic  and  very  rare. 

Anophthalmos  is  absence  of  the  eyeball.  It  may  b^ 
congenital. 

iSegalophthalmos  is  enlarged  eyeball. 


118  DISEASES  OF  THE  EYEBALL. 

Microphthalmos  is  a  small  eyeball.     Congenital. 
A  shrunken  eyeball  resulting  from  extensive  inflammation 
is  known  as  phthisis  bulbi. 

BUPHTHALMOS. 

Synonyms. — Hydrophthalmos ;  Keratoglobus ;  Congenital 
glaucoma. 

Definition. — A  progressive  enlargement  of  the  whole  eye, 
with  increased  tension.     Begins  in  utero  or  in  infancy. 

INJURIES  OF  THE  EYEBALL. 

Contusions  and  wounds  of  the  eyeball  have  been  described 
under  diseases  of  the  various  structures  of  the  eye. 

FOREIGN  BODIES  WITHIN  THE  EYEBALL. 

Perforating  wounds  with  retention  of  a  foreign  body  are 
always  serious  injuries.  Aside  from  the  danger  of  infection 
carried  in  by  the  foreign  body,  or  from  the  wound,  the  pres- 
ence of  a  foreign  substance  generally  leads  to  destructive 
changes. 

Diagnosis. — The  history,  character  of  the  wound,  be- 
havior of  the  eye  after  the  injury,  and  sometimes  a  view  of 
the  foreign  body,  will  usually  determine  its  presence  in  the 
eye.  If  the  particle  be  iron  or  steel,  a  magnetic  needle  prop- 
erly adjusted,  as  in  the  sideroscope  of  Asmus,  may  be  used. 
Or,  when  a  large  magnet  is  placed  before  the  eye,  pain  is 
sometimes  felt.  The  ;i'-ray  has  also  been  successfully  em- 
ployed in  localizing  foreign  bodies. 

Treatment. — If  the  foreign  body  be  of  wood,  stone,  brass, 
or  glass,  it  should  be  removed  with  forceps,  hook,  or  in  any 
way  possible.  If  magnetic,  and  in  the  vitreous,  it  may  be 
removed  through  the  original  wound,  through  an  incision  in 
the  sclerotic,  or  may  be  brought  around  the  lens  into  the  ante- 
rior chamber.  For  this  purpose,  a  large  magnet,  such  as  that 
of  Haab,  is  best  employed,  although  smaller  magnets  are 


QUESTIONS.  119 

sometimes  of  service,  and  may  even  be  introduced  into  the 
wound.  It  is  well  to  remember  that  small  aseptic  foreign 
bodies  may  become  encysted  and  remain  innocuous  for  many 
years.  Even  after  successful  extraction,  degenerative  changes 
are  likely  to  occur  after  a  considerable  time. 

ENUCLEATION. 

This  operation  is  performed  under  general  anaesthesia. 
The  conjunctiva  is  cut  all  about  the  edge  of  the  cornea  with 
scissors.  Each  muscle  is  then  taken  on  a  strabismus  hook 
and  cut  close  to  the  eyeball.  A  strong  scissors,  which  is 
curved  on  the  flat,  is  passed  backward  close  to  the  eyeball  on 
tiie  nasal  side  until  the  optic  nerve  is  felt.  This  is  severed 
with  one  stroke.  The  eye  is  then  easily  freed  from  remaining 
adhesions.  After  cleansing  with  an  antiseptic  (bichloride  of 
mercury  1 :  5000)  the  conjunctiva  should  be  brought  together 
with  a  purse-string  suture.  An  artificial  eye  may  be  worn  in 
two  or  three  weeks. 

EVISCERATION  (EXENTERATIO  BULBI). 

A  substitute  for  enucleation,  having  the  advantage  of 
leaving  a  better  stump  for  an  artificial  eye.  The  eye  is 
opened  by  excising  the  cornea,  and  the  contents  are  scraped 
out,  leaving  only  the  sclera.  A  hollow  sphere  of  glass  or 
silver  is  sometimes  introduced  (Mules'  operation), 

QUESTIONS. 

Define  pulsating  exophthalmos  and  exophthalmic  goitre. 
What  are  the  dangers  of  perforating  wounds  of  the  eyeball? 
How  may  the  diagnosis  of  the  presence  of  foreign  bodies  within  the  eye- 
ball be  made? 

Give  the  treatment  of  foreign  body  witlnn  the  ej'^eball. 
Describe  enucleation  and  evisceration. 


120  GLAUCOMA. 

CHAPTER  XYII. 
GLAUCOMA, 

Definition. — A  disease  characterized  hy  increase  of  intra- 
ocular tension. 

Varieties. — Acute  inflammatory  glaucoma,  chronic  inflam- 
matory glaucoma,  simple  glaucoma,  and  secondary  glaucoma. 

ACUTE  INFLAMMATORY  GLAUCOMA. 

Predisposing  causes  are,  age  over  forty,  arterial  sclerosis, 
high  arterial  tension,  and  hypermetropia. 

Exciting  causes  are  physical  and  mental  depression,  in- 
somnia, and  the  use  of  a  mydriatic. 

Pathology. — A  current  normally  passes  from  the  ciliary 
body,  around  the  lens,  through  the  pupil,  anterior  chamber, 
and  ligamentum  pectinati  in  the  iris  angle,  into  Schlemm's 
canal.  Interference  with  this  system  of  circulation,  such  as 
would  be  caused  by  blocking-up  of  the  iris  angle  and  cutting 
off  the  outflow,  with  or  without  increase  in  the  secretion,  will 
be  followed  by  rise  in  intraocular  tension.  Upon  this  theory 
most  explanations  of  glaucoma  are  founded. 

Prodromal  Symptoms. — For  a  year  or  two  the  patient  may 
complain  of  a  failure  of  accommodation,  which  shows  itself 
by  the  need  of  stronger  glasses,  or  of  occasional  attacks  of 
blurred  vision  and  halos  about  the  light. 

Symptoms  of  attack  begin  suddenly  with  a  severe  pain  in 
the  eye  and  head.  There  may  be  some  temperature,  nausea, 
and  vomiting.  The  lids  are  swollen,  the  eyeball  is  deeply  con- 
gested, cornea  steamy  and  ansesthetic,  anterior  chamber  veiy 
shallow,  pupil  dilated  and  oval  in  shape,  and  the  iris  dis- 
colored. The  fundus  can  not  usually  be  made  out  on  account 
of  the  cloudiness  of  the  media.  Vision  may  be  diminished 
in  a  few  hours  even  to  perception  of  light.  Tension  is  very 
high.  This  attack  lasts  from  a  few  hours  to  a  few  days; 
then  all  acute  symptoms  gradually  subside,  leaving  the  vision 


ACUTE  INFLAMMATORY  GLAUCOMA. 


121 


more  or  less  permanently  impaired.  The  other  eye  may  be 
affected  in  a  similar  manner  at  any  time. 

Recurrence. — After  a  few  weeks  or  months  the  acute 
attack  is  repeated,  and  if  no  treatment  is  given,  the  eye 
later  will  pass  into  a  condition  of  subacute  or  chronic  glau- 
coma. 

Diagnosis. — Although  acute  glaucoma  is  not  a  common  dis- 
ease, the  importance  of  differential  diagnosis  is  evident  from 
the  fact  that  if  the  condition  is  mistaken  for  iritis  and  atro- 
pine prescribed,  the  results  will  be  disastrous.  The  follow- 
ing table  will  assist  the  student.  It  applies  to  acute  condi- 
tions. 


Age 

Tension  ..... 
Secretion  .... 
Congestion    .    .    . 

Cornea  

Anterior  chamber 

Iris 

Pupil 

Pain 

Vision 

Treatment     .    .    . 


Glaucoma. 


Over  forty. 

Plus. 

None,  or  watery. 

(General,  especi- 
ally scleral. 

Cloudy  and  steamy 
surface. 

Shallow. 

Discolored. 

Dilated,  oval. 

Severe,  continuous. 
Much  reduced. 
Eserine,    pilocarp- 
ine, iridectomy. 


Iritis. 


Any. 

Normal. 

None,  or  watery. 

General,  especially 

circumcorneal. 
Cloudy. 


Unchanged.  Unchanged. 

Discolored.  Unchanged. 

Contracted,       syn-  Unchanged. 

echiae. 
Especially  at  night.  None. 
Somewhat  reduced  Good. 
Atropine.  !  Astringent. 


Conjunctivitis. 


Any. 
Normal. 
Mucopurulent. 
Conjunctival,  espe- 
cially of  lids. 
Clear. 


Prognosis. — After  proper  treatment,  the  results  in  acute 
glaucoma  are  usually  satisfactory.  It  must  be  borne  in  mind, 
however,  that  the  operation  or  after-treatment  at  times  pre- 
cipitates an  attack  in  the  other  eye. 

Treatment. — Persons  over  forty,  complaining  of  rapidly 
failing  accommodation,  transient  blurs,  and  halos  should  be 
kept  under  observation.  In  the  acute  attack  the  patient 
should  be  kept  in  bed  and  given  a  full  dose  of  an  opiate. 
Locally,  eserine  sulphate  (0.5  per  cent.)  should  be  instilled 
at  first  every  hour  or  two ;  later,  three  to  five  times  a  day. 


122  GLAUCOMA. 

But  if  the  tension  remains  high  and  vision  becomes  worse, 
iridectomy  should  be  performed  as  follows :  A  general  anaes- 
thetic is  necessary  in  acute  glaucoma.  After  cleansing  the 
eye,  the  speculum  is  adjusted.     The  fixation  forceps  are  then 

Fig.  29. 


Keratome. 

placed  in  the  conjunctiva  below  the  cornea,  and  a  lance-knife 
or  bent  keratome  is  introduced  into  the  sclera  above,  about 
1  mm.  back  of  the  clear  cornea,  and  the  point  is  passed  into 
the  anterior  chamber  over  the  iris.  After  withdrawing  the 
knife,  the  iris  forceps  is  introduced  and  the  iris  grasped  near 

Fig.  30. 


Iridectomy  for  glaucoma.    (De  Weeker.) 

the  pupillary  edge  and  drawn  out  of  the  wound.  The  iris  is 
then  cut  off  with  two  snips  of  the  scissors  very  near  to  the 
eyeball.  The  cut  edges  of  the  iris  are  replaced  with  a  spatula, 
making  the  ideal  keyhole  iridectomy.  Some  operators  use 
the  Graefe  cataract-knife  for  the  incision. 

CHRONIC  INFLAMMATORY  GLAUCOMA. 

Definition  and  Symptoms. — After  repeated  attacks  of  acute 
glaucoma,  or  primarily,  the  tension  may  become  permanently 
increased.  There  is  more  or  less  pain,  enlargement  of  scleral 
vessels,  shallow  anterior  chamber,  oval,  enlarged  and  immov- 
able pupil.  Vision  is  reduced  or  destroyed.  Later,  when 
there  is  no.  perception  of  light,  very  high  tension,  cataractous 
lens,  wide  pupil,  and  shallow  anterior  chamber,  the  condition 
is  known  as  Absolute  Glaucoma, 


SIMPLE  GLAUCOMA.  123 


SIMPLE  GLAUCOMA. 

Synonyms. — Chronic  noninflammatory  glaucoma ;  Glaucoma 
simplex. 

Etiology. — Age  over  forty.  Hyperopic  refraction,  arterio- 
sclerosis, and  high  arterial  tension. 

Pathology. — See  Acute  Inflammatory  Glaucoma. 

Subjective  Symptoms. — The  only  complaint  from  the  patient 
is  gradual  decrease  in  vision  and  halos  about  artificial  light. 
There  is  no  pain,  only  occasionally  a  sense  of  pressure. 

Objective  Symptoms. — The  eye  will  be  found  free  from  con- 
gestion, except  perhaps  a  few  enlarged  scleral  vessels.  The 
anterior  chamber  may  or  may  not  be  shallow.  The  pupil 
may  be  normal  and  movable,  or  somewhat  dilated.  The  lens 
and  vitreous  are  clear.  The  optic  nerve  is  atrophic,  white 
or  gray,  and  shows  the  characteristic  condition  known  as 
"  cupped  disk."  Just  inside  the  scleral  ring,  which  is  broad, 
the  nerve  falls  abruptly  to  a  deeper  level,  and  the  bloodvessels 
will  be  seen  dropping  over  this  edge  and  appearing  again  at 
the  bottom  of  the  excavation.  The  arteries,  if  closely  ob- 
served, will  be  seen  to  pulsate.  The  tension  of  the  eye  is 
increased,  but  not  constantly,  at  times  being  quite  normal. 
The  field  of  vision  is  contracted  concentrically,  but  more 
especially  on  the  nasal  side.  There  may  be  irregular  con- 
traction in  any  part  of  the  field,  and  even  isolated  scotomata. 
The  acuity  of  vision  is  usually  reduced,  although  in  some 
cases  the  field  is  much  contracted  before  the  vision  is  affected. 

Course. — Both  eyes  are  usually  afi'ected  at  about  the  same 
time.  The  disease  continues  over  a  number  of  years.  If  no 
treatment  is  undertaken,  it  ends  in  absolute  glaucoma. 

Diagnosis. — In  some  cases  the  appearance  is  very  similar  to 
atrophy  of  the  optic  nerve  with  excavation,  and  may  only  be 
distinguished  by  detecting  increase  of  tension,  which  is  not 
at  all  times  present.  In  prescribing  mydriatics  such  as  atro- 
pine for  a  patient  over  fifty,  the  possibility  of  glaucomatous 
tendencies  should  be  borne  in  mind,  since  these  drugs  tend 
to  increase  intraocular  tension. 

Prognosis. — Although  the  prognosis  is  poor,  the  disease  will 


124  GLAUCOMA. 

usually  be  arrested,  or  at  least  the  rapidity  of  its  progress 
decreased  by  operation.  The  success  of  operative  treatment 
is  in  general  proportionate  to  the  size  of  the  field  of  vision. 
On  rare  occasions  the  eye  operated  upon  will  become  more 
rapidly  worse.  Sometimes  there  is  no  effect.  Increased  ten- 
sion, with  inflammatory  signs,  immediately  after  operation, 
is  of  rare  occurrence.  This  latter  condition  is  known  as 
malignant  glaucoma,  and  results  in  loss  of  the  eye. 

Treatment. — Eserine  (0.2  per  cent.)  t.  i.  d.,  or  pilocarpine 
(1  per  cent.)  t.  i.  d.,  should  be  given  as  temporary  palliative 
treatment.  An  iridectomy,  broad  at  the  base  of  the  iris, 
should  be  performed,  as  already  described.  It  may  be  done 
under  cocaine.  Sclerotomy  as  a  substitute  for  iridectomy 
may  be  tried  :  The  eye  is  entered  with  a  Graefe  knife,  as  for 
cataract  incision,  but  the  knife  is  withdrawn  before  the  flap  is 
completed  (anterior  sclerotomy).  Or,  the  knife  is  entered 
well  back  in  the  sclera  and  the  eye  pierced  behind  the  lens 
(posterior  sclerotomy).  Of  late,  excision  of  the  superior  cer- 
vical ganglion  (sympathectomy)  has  been  performed  for  the 
relief  of  glaucoma  with  some  success. 

Secondary  Glaucoma  is  generally  due  to  mechanical 
causes,  such  as  filling  up  of  the  iris  angle,  swelling  of  the 
lens,  dislocation  of  the  lens,  hemorrhages,  intraocular  tumors, 
injuries,  choroiditis,  retinitis,  and  closure  of  the  pupil. 

Hemorrhagic  Glaucoma. — A  form  which  appears  after 
retinal  hemorrhages  of  various  origin.  Its  treatment  is  un- 
satisfactory, iridectomy  being  generally  disastrous  from  the 
occurrence  of  further  hemorrhages. 

QUESTIONS. 

Into  what  varieties  may  glaucoma  be  divided? 

Give  cause,  symptoms,  and  treatment  of  acute  inflammatory  glaucoma. 

Give  differential  diagnosis  between  acute  glaucoma,  iritis,  and  conjunc- 
tivitis. 

Give  pathology,  symptoms,  diagnosis,  prognosis,  and  treatment  of  simple 
glaucoma, 


SYMPATHETIC  OPHTHALMIA.  125 

CHAPTER   XVIII. 
SYMPATHETIC  OPHTHALMIA. 

Definition. — A  condition  in  which  a  healthy  eye  becomes 
the  seat  of  a  clestructiv^e  inflammation  transferred  from  the 
other  eye,  which  has  been  the  subject  of  a  similar  inflam- 
mation usually  following  a  perforating  injury  of  the  eyeball. 
The  injured  eye  is  called  the  exciting  eye ;  the  other,  the  sym- 
pathizing eye.  Although  sympathetic  ophthalmia  is  a  com- 
paratively rare  disease,  the  possibility  of  its  occurrence  should 
not  be  overlooked  on  account  of  its  terrible  consequences. 

Etiology. — Children  are  more  susceptible  than  adults.  The 
type  of  inflammation  in  the  exciting  eye  is  usually  a  chronic 
plastic  iridocyclitis.  This  is  produced  in  the  majority  of  cases 
by  a  perforating  wound  involving  the  so-called  "  danger  zone," 
or  ciliary  region — a  zone  J  inch  wide  about  the  cornea.  There 
may  or  may  not  be  retention  of  a  foreign  body  within  the 
eyeball.  It  may  follow  cataract  extraction.  The  exciting 
eye  may  be  one  which  has  had  a  perforating  ulcer  of  the 
cornea  with  incarceration  of  iris  or  ciliary  body.  Instances 
have  been  reported  in  which  there  was  no  evidence  of  per- 
foration, traumatic  or  otherwise.  Eyes  destroyed  by  purulent 
inflammation,  as  a  rule,  do  not  produce  sympathy. 

Pathology. — The  mode  of  transmission  of  the  inflammation 
is  still  undecided.  The  theories  are  (a)  irritation  in  the  sym- 
pathizing eye,  producing  disturbances  of  nutrition  and  circu- 
lation, and,  finally,  inflammation  through  the  agency  of  the 
intimate  nerve  relationship ;  (b)  transferrence  of  germs  by 
means  of  communication  through  the  optic  nerve  or  sheath ; 
(c)  transmission  of  infectious  germs  or  toxins  by  means  yet 
unknown.     The  last  is  the  commonly  accepted  theory. 

Symptoms  of  the  Disease  in  the  Exciting  Eye. — The  eye  is 
more  or  less  congested  and  painful.  It  is  tender  in  the  ciliary 
region  when  pressure  is  made  through  the  upper  lid ;  shows 
minus  tension ;  posterior  synechise  or  pupil  blocked  with 
exudate. 


126  SYMPATHETIC  OPHTHALMIA. 

Symptoms  of  the  Disease  in  the  Sympathizing  Eye. — There 
is  a  chronic  inflammation  involving  the  uveal  tract  (iris, 
ciliary  body,  and  choroid).  It  may  begin  (a)  with  slight 
ciliary  congestion,  punctate  deposits  on  Descemet\s  membrane, 
deep  and  cloudy  anterior  chamber,  slightly  dilated  pupil,  a 
few  synechise  and  opacities  in  the  vitreous  (so-called  serous 
iritis) ;  {b)  or  the  disease  may  begin  at  once  as  a  plastic  irido- 
cyclitis with  pain,  ciliary  tenderness,  ciliary  congestion,  small 
and  blocked  pupil,  opacities  of  vitreous,  and  later  formation 
of  bands  and  detachment  of  the  retina  and  shrinking  of  the 
eyeball ;  (c)  the  disease  may  also  appear  first  as  a  neuro- 
retinitis. 

Course. — Sympathetic  ophthalmia  appears  between  the  third 
week  and  the  sixth  month  after  the  original  injury.  The 
extreme  limits  are  two  weeks  and  twenty  or  more  years.  The 
second  eye  is  likely  to  be  attacked  during  a  period  of  active 
inflammation  in  the  exciting  eye.  Although  there  are  usually 
some  symptoms  of  sympathetic  irritation  (see  page  127) 
before  the  genuine  attack  sets  in,  it  often  appears  without 
warning. 

The  disease  in  the  sympathizing  eye  runs  a  chronic  course, 
with  exacerbations. 

Prognosis.  —  Sympathetic  inflammation  once  established 
leads  to  blindness  in  the  vast  majority  of  cases.  Those  ap- 
pearing as  neuroretinitis  are  the  most  favorable. 

Treatment. — The  enucleation  of  a  suspected  eye,  if  we  can 
be  assured  that  the  sympathetic  process  has  not  begun,  is  a 
positive  preventive,  and  should  be  practised  in  cases  of  hope- 
lessly extensive  wounds.  Further,  an  eye  which  has  been 
the  subject  of  an  injury  especially  involving  the  ciliary  body 
or  containing  a  foreign  body,  and  which  shows  signs  of  plastic 
iridocyclitis  with  ciliary  tenderness  and  in-drawn  scar,  should 
be  enucleated.  Evisceration  of  the  contents  of  the  eyeball  or 
section  of  the  optic  and  ciliary  nerves  are  advocated  by  some 
as  a  substitute  for  enucleation. 

When  sympathetic  ophthalmia  is  established,  enucleation 
of  the  exciting  eye  is  usually  considered  of  no  value — at  all 
events,  should  not  be  performed  if  any  vision  remains  in  the 


hefraction,  127 

exciting  eye.  After  cessation  of  the  disease  the  first  eye  may 
be  the  better.  The  patient  shoukl  be  treated  with  rest  in 
bed,  mercury — either  by  inunctions  or  internally — and  by 
diaphoretics.  The  eye  should  be  kept  under  the  influence 
of  atropine  and  hot  fomentations.  If  the  inflammation  finally 
subsides  without  shrinking  of  the  eyeball,  an  attempt  may 
be  made  to  obtain  a  clear  pupil  by  iridectomy  or  iridotomy, 
but  it  will  usually  close  again. 

SYMPATHETIC  IRRITATION. 

Definition. — This  is  a  distinct  affection  apart  from  sympa- 
thetic inflammation.  It  is  a  neurosis,  showing  in  the  sympa- 
thizing eye  photophobia,  lachrymation,  symptoms  of  asthe- 
nopia, impaired  accommodation,  and  contraction  of  the  field 
of  vision.  In  its  simplest  form  it  may  be  produced  by  irrita- 
tion, such  as  arises  from  the  presence  of  a  foreign  body  on 
the  cornea,  or  may  appear  when  the  exciting  eye  is  one 
capable  of  producing  sympathetic  ophthalmia.  These  phe- 
nomena are  likely  to  recur  at  intervals,  and  may  be  the  pre- 
cursors of  the  true  inflammation.  Hence  blind  offending  eyes 
should  be  removed. 

QUESTIONS. 

Define  sympathetic  ophthalmia. 

What  is  the  mode  of  transmission  from  one  eye  to  the  other? 

Describe  the  disease  in  the  exciting  eye  and  in  the  sympathizing  eye. 

What  are  the  course  and  the  prognosis  ? 

Give  the  rules  for  enucleation  of  the  offending  eye. 

What  is  sympathetic  irritation  ? 


CHAPTER   XIX. 
REFRACTION. 

SUBJECTIVE  EXAMINATION. 

A  test-case  consists  of  lenses  and  prisms  graded  in  strength. 

Lenses. — A  lens  is  made  of  glass  or  crystal,  with  at  least 
one  surface  curved,  and  has  the  power  of  refracting  or  changing 
the  direction  of  rays  of  light. 


128  REFRACTION. 

Prisms. — A  prism  is  wedge-shaped,  and  bends  rays  of  light 
toward  its  base.  Prisms  are  numbered  (a)  according  to  the 
angle  of  the  two  sides  ;  or  (6)  by  the  amount  of  angular  devia- 
tion of  a  ray  of  light,  which  is  produced  by  the  prism  :  the 
latter  may  be  considered  about  one-half  the  former ;  (c)  devia- 
tion measured  in  one-hundredths  of  a  given  arc  (centrad). 

Spherical  Convex  Lens. — Usually  biconvex.  Converges 
rays  of  light  to  a  focus.  When  the  entering  rays  are  parallel, 
the  distance  from  the  optical  centre  of  the  lens  to  tlie  focus 
is  called  the  principal  focal  distance.  The  stronger  or  more 
convex  the  lens,  the  shorter  the  focal  distance. 

Convex  Cylindrical  Lens. — May  be  represented  by  a  section, 
cut  in  one  plane,  from  a  solid  cylinder  parallel  to  the  axis  of 
the  cylinder.  One  surface  would  be  plane,  the  other  surface 
would  have  a  convex  meridian,  and  the  other  meridian  at 
right  angles  to  it — a  straight  line.  The  focus  is  determined 
for  the  meridian  of  greatest  curvature,  and  is  a  line  instead 
of  a  point. 

Concave  Spherical  Lens. — Usually  biconcave.  Diverges  rays 
of  light  and  has  no  real  focus.  The  focal  distance  is  found  by 
extending  the  divergent  rays  backward  until  they  meet.  The 
same  principles  then  apply  as  for  convex  sphericals. 

Concave  Cylindrical  Lens. — Corresponds  to  convex  cylin- 
drical lens,  but  has  one  concave  meridian. 

Numbering  of  Lenses. — Lenses  are  numbered  according  to 
two  methods : 

1.  The  inch  system,  which  designates  the  strength  by  the 
inverse  of  the  principal  focal  distance  in  inches  :  -^-q"  signifies 
a  lens  whose  focal  distance  is  20  inches. 

2.  The  diopter  (dioptry,  dioptre)  system.  A  lens  with  a 
focal  distance  of  one  metre  is  the  unit.  A  lens  of  one-half 
this  focal  distance  would  be  called  2  D. ;  one-quarter  of  this 
distance,  4  D. 

One  system  may  be  converted  into  the  other,  approximately, 
by  dividing  the  number  of  the  lens,  in  either  system,  into  40 — 
e.  g.,  2  D.  equals  20  inches,  or,  10  inches  equals  4  D.  +  sig- 
nifies convex,  and  —  concave,  lenses. 

Diagnosis  with  Lenses. — After  recording  the  vision,  as  de- 


OBJECTIVE  EXAMINATION.  129 

scribed  on  page  26,  if  it  is  f  J-,  one  may  conclude  that  the 
patient  is  either  emmetropic  or  hypermetropic.  If  a  convex 
spherical  lens  is  held  before  the  eye  and  the  vision  still  remains 
perfect,  the  eye  is  hypermetropic  and  the  strongest  glass  ac- 
cepted measures  the  manifest  hypermetropia.  If  no  plus  glass 
is  accepted,  the  eye  is  probably  practically  emmetropic.  If  the 
vision  is  not  equal  to  f^,  and  the  cause  is  a  refractive  error, 
this  is  either  myopia,  astigmatism,  or  high  hypermetropia. 
Concave  spherical  lenses  should  be  tried,  and  if  the  vision  is 
made  perfect,  the  weakest  lens  measures  the  myopia.  If  not 
made  perfect,  convex  and  concave  cylinders  should  be  tried 
at  all  axes  until  vision  is  improved.  The  improvement  of 
vision  by  cylinders  shows  the  presence  of  astigmatism. 

OBJECTIVE  EXAMINATION. 

Ophthalmoscope.— The  direct  method  is  employed.  The 
observer  must  learn  to  relax  his  accommodation.  The  accom- 
modation of  the  patient  usually  relaxes  under  the  examination, 
or  a  cycloplegic  (atropine,  1  per  cent.,  or  homatropine,  2  per 
cent.)  may  be  used.  Hypermetropia  is  measured  by  noting 
the  strongest  convex  lens  of  the  ophthalmoscope  through 
which  the  fundus  may  be  clearly  seen,  and  myopia  by  the 
weakest  concave  lens.  Astigmatism  gives  a  streaked  appear- 
ance to  the  fundus.  Each  meridian  may  be  measured,  as  is 
simple  hypermetropia  or  myopia,  by  focussing  upon  the  retinal 
vessels.  With  practice,  the  refraction  may  Jbe  estimated  with 
great  accuracy. 

Skiascopy  (Retinoscopy,  Shadow  Test).— A  skiascope, 
or  retinoscope,  is  a  circular  plane  or  concave  mirror  with  a 
small  central  aperture.  If  the  light  is  placed  back  of  the 
patient,  and  the  observer  stands  about  1.5  metres  in  front  and 
reflects  the  light  into  the  patient^s  eye,  the  pupil  will  show  a 
red  reflex.  When  the  reflected  light  is  moved  slowly  from 
side  to  side,  the  red  pupil  reflex  will  appear  to  move  either  in 
the  same  or  in  the  opposite  direction.  If  the  reflex,  or  the 
shadow  which  borders  it,  moves  in  the  same  direction,  when  a 
plane  mirror  is  used,  the  eye  is  hypermetropic.     If  in  the 

9— E.  E. 


130  REFRACTION. 

opposite  direction,  the  eye  is  myopic.  The  reverse  is  true  if 
the  concave  mirror  is  used.  By  placing  lenses  before  the 
patient's  eye,  one  may  determine  the  exact  correction  when 
there  is  no  movement  of  the  reflex.  The  different  meridians 
of  astigmatism  may  be  separately  measured  in  this  way. 
Skiascopy  is  the  most  accurate  method  of  determining  refrac- 
tion. 

Ophthalmometer. — An  instrument  for  the  determination 
of  variations  in  the  curvature  of  the  cornea  by  means  of 
reflexes.  As  astigmatism  is,  for  the  most  part,  in  the  cornea, 
the  instrument  is  of  value  in  confirming  other  tests. 

INDIVIDUAL  ERRORS  OF  REFRACTION. 

If  parallel  rays  of  light  are  brought  to  a  focus  on  the  retina, 
with  the  accommodation  at  rest,  the  refraction  is  normal  and 
the  eye  is  said  to  be  emmetropic.  If  under  these  conditions 
the  rays  are  not  brought  to  a  focus  upon  the  retina,  the  eye  is 
ametropia  The  varieties  of  ametropia,  or  errors  of  refraction, 
are  (I.)  hypermetropia,  (II.)  myopia,  and  (III.)  astigmatism. 
Anisometropia  is  a  term  commonly  employed  to  denote  that 
one  eye  differs  markedly  from  the  other  in  refraction. 

I.  HYPERMETROPIA. 

Synonym. — Farsightedness. 

Definition. — A  condition  in  which,  with  the  accommodation 
at  rest,  parallel  rays  of  light  fall  behind  the  retina. 

Hypermetropia  is  a  congenital  defect,  and  never  increases. 
The  eyeball  is  too  short  in  anteroposterior  diameter  for  the 
refractive  power  of  the  media.  Thus  the  focus  falls  behind 
the  retina,  but  while  the  accommodation  (see  page  27)  is 
strong,  the  focus  may  be  brought  forward. 

Ssrmptoms. — The  patient  complains  of  asthenopia,  under 
which  head  are  classed  the  symptoms  produced  by  eye-strain  : 
pain  in  the  eyes,  headache  (especially  frontal),  blurring  and 
running  together  of  type,  conjunctivitis,  photophobia,  tiring 
of  the  eyes,  dizziness,  etc. 


INDIVIDUAL  ERMons  OP  HEPMACTION.  131 

Tests. — When  the  vision  is  tested  at  a  distance,  it  will  be 
found  perfect  unless  the  patient  has  lost  his  accommodation, 
but  he  will  see  as  well  with  a  convex  glass.  The  strongest 
convex  lens  through  which  the  patient  sees  as  well  as  without, 
measures  the  manifest  hypermetropia.  A  cycloplegic  such  as 
homatropine  hydrobromate  (2  per  cent,  solution)  dropped  into 
the  eyes  three  times  during  an  hour,  or  atropine  sulphate  (1 
per  cent.)  three  times  a  day  for  three  days,  will  paralyze  the 

Fig.  31. 


Ck>rTection  of  hypermetropia. 

accommodation,  and  the  vision  will  then  fall  below  the  nor- 
mal, because  the  patient  can  no  longer  use  his  accommodation 
and  bring  forward  the  focus  upon  the  retina.  The  convex 
lens,  which  then  gives  him  perfect  vision,  will  be  stronger 
than  that  for  the  manifest  hypermetropia,  and  measures  the 
exact  refraction  of  the  eye  or  total  hypermetropia.  The  differ- 
ence between  the  manifest  and  total  hypermetropia  is  called 
the  latent  hypermetropia.  As  one  grows  older,  the  accom- 
modation weakens,  and  the  latent  hypermetropia  becomes  less 
until  about  fifty  or  fifty-five,  when  the  manifest  equals  the 
total,  if  it  does  not  before. 

Example. — If  a  patient  under  forty  has  perfect  vision  at 
distance — e.g.,  |^  with  each  eye,  and  sees  as  well  with  +2  D. 
spherical,  and  with  no  stronger  lens,  he  is  said  to  accept 
+2  D.,  or  to  have  manifest  hypermetropia  of  that  amount. 
If  the  eyes  are  put  under  the  influence  of  atropine,  his  vision 
will  be  reduced  to  perhaps  f^,  but  with  +3.5  D.  is  brought 
to  1^.  He  thus  has  total  hypermetropia  +3.5  D.  and  latent 
+  1.5  D. 

Treatment. — In  young  persons  it  is  well  to  examine  the 


132  REFRACTION, 

eyes  with  a  cydoplegic.  When  the  observer  is  skilled  in  the 
use  of  the  ophthalmoscope,  skiascope,  and  ophthalmometer, 
the  use  of  cycloplegics  becomes  less  necessary,  especially  in 
adults.  In  some  cases,  particularly  those  with  muscular  errors, 
it  is  best  to  give  the  correction  for  total  hypermetropia  (full 
correction).  But  since  the  distant  vision  will  be  blurred  with 
these  lenses  when  the  effects  of  the  atropine  have  passed, 
it  is  generally  customary  to  correct  the  manifest  error  and 
a  little  of  the  latent,  in  addition. 

In  children  the  glasses  should  be  worn  constantly.  I71 
adults  they  may  be  used  only  for  close  work  if  the  error  is 
not  large. 

n.  MYOPIA. 

Definition. — Myopia  is  a  condition  in  which  the  focus  for 
parallel  rays  of  light  falls  in  front  of  the  retina.  The  antero- 
posterior diameter  is  too  long.     It  is  a  diseased  condition. 

Etiology. — Myopia  may  be  congenital,  but  is  generally 
acquired,  beginning  usually  between  the  ages  of  eight  and 
fifteen.  In  the  latter  form  there  may  be  hereditary  predis- 
position, but  improper  use  of  the  eyes  is  the  direct  cause. 

FiQ.  32. 


Correction  of  myopia. 

Complications. — There  is  bulging  of  the  posterior  segment 
of  the  eyeball  (posterior  staphyloma).  In  high  degrees  this 
is  accompanied  by  a  chronic  inflammatory  process  (cho- 
roiditis), which  produces  changes  in  the  fundus,  especially  at 
the  macula  and  about  the  nerve.  There  is  also  a  tendency 
toward  hemorrhages  in  the  fundus,  detachment  of  the  retina, 


ASTIGMATISM.  133 

and  opacities  of  the  vitreous.  Insufficiency  of  the  internal 
recti  is  a  common  complication,  and  at  times  divergent  stra- 
bismus occurs. 

Symptoms. — The  young  patient  begins  to  complain,  in 
school,  of  poor  vision  at  a  distance.  There  is  usually  no 
asthenopia.  If  the  disease  has  reached  a  high  degree,  near 
work  is  held  very  close  to  the  eyes. 

Tests. — The  distant  vision  is  found  considerably  reduced, 
while  perfect  at  the  near  point.  Concave  spherical  lenses  bring 
the  distant  vision  to  normal  if  there  are  no  complications. 
The  weakest  concave  lens  which  gives  perfect  vision  measures 
the  myopia.  Atropine  is  not  so  important  as  in  hyperme- 
tropia,  since  there  is  a  natural  tendency  to  relax  the  accom- 
modation. Low  degrees  of  myopia,  how^ever,  should  be  tested 
with  a  cycloplegic,  because  spasm  of  accommodation,  or  false 
myopia,  is  possible,  and  gives  poor  vision,  improved  by  weak 
concave  lenses. 

Course. — Myopia  may  increase  through  youth  and  reach  a 
high  degree  before  the  twenty-fifth  year.  It  is  then  called 
progressive.  When  rapidly  progressive,  it  is  known  as  malig- 
nant. 

Treatment. — Near  work  should  be  restricted,  and  the  eyes 
used  only  under  the  most  favorable  conditions  as  to  proper 
position  at  desk,  illumination,  etc.  Attention  should  be  given 
to  the  general  health  and  exercise  out-of-doors  prescribed. 
For  the  lower  degrees  of  myopia,  it  is  commonly  agreed  that 
the  full  correction  of  the  error  should  be  worn  constantly. 
In  high  degrees  and  in  patients  over  forty,  a  w^eaker  glass 
should  be  given  for  near  work.  The  crystalline  lens  may  be 
removed  by  absorption  or  extraction  in  myopia  over  — 15  D. 
This  more  or  less  exactly  neutralizes  the  myopia. 


III.  ASTIGMATISM. 

Definition. — ^A  condition  in  which  one  meridian  varies  from 
another  in  refractive  power.  Astigmatism  is  largely  in  the 
anterior  surface  of  the  cornea.  The  corneal  surface  may  be 
likened  to  that  of  the  bowl  of  a  spoon.     Some  astigmatism. 


134  REFRACTION. 

may  be  present  in  the  lens.  There  may  be  irregularities  in 
the  surface  of  the  cornea  (irregular  astigmatism) ;  but,  in  the 
ordinary  acceptance  of  the  term  (regular  astigmatism),  the 
extremes  of  curvature  are  at  right-angles  to  each  other.  The 
axis  of  the  astigmatism,  as  of  the  cylinder  which  corrects  it, 
is  that  meridian  which  is  nearest  the  emmetropic.  There  is 
no  one  point  as  a  focus  for  the  astigmatic  eye,  but  there  are 
two  foci — one  behind  the  other,  and  each  a  line  at  right-angles 
to  the  other.  Astigmatism  changes  only  gradually  through 
life. 

Varieties. — Simple  hyperopic  astigmatism:  one  meridian 
emmetropic ;  the  other,  at  right-angles,  hypermetropic. 

Simple  myopic  astigmatism :  one  meridian  emmetropic ;  the 
other  myopic. 

Compound  hypermetropic  astigmatism :  one  meridian  hyper- 
metropic ;  the  other  more  hypermetropic. 

Compound  myopic  astigmatism :  one  meridian  myopic ;  the 
other  more  myopic. 

Mixed  astigmatism :  one  meridian  hypermetropic ;  the  other 
myopic. 

Symptoms. — There  is  complaint  of  poor  vision,  of  seeing 
lines  in  one  direction  better  than  another,  and  of  asthenopia. 

Tests. — The  vision  is  affected  according  to  the  degree  of  the 
astigmatism,  both  for  near  and  distance.  Cylinders  at  the 
proper  axis  will  give  improvement  in  vision.  Atropine 
should  be  used  for  the  examination  under  the  same  conditions 
as  in  hypermetropia.  A  further  subjective  test  is  made  with 
a  card  having  lines  which  radiate  in  all  directions  from  a 
common  centre,  like  spokes  of  a  wheel.  The  astigmatic  eye 
will  not  see  all  the  lines  with  equal  distinctness,  and  cylinders 
can  be  tried  at  all  axes  until  the  lines  appear  alike. 

Treatment. — It  is  desirable  to  order  as  weak  a  cylinder  as 
possible. 

ERRORS  OF  ACCOMMODATION. 

Presbyopia.^The  near  point  of  monocular  vision  (punctum 
proximum)  is  about  two  and  one-half  inches  in  the  young 
child.     This  near  point  gradually  recedes  until  between  forty 


THE  MUSCLES  OF  THE  EYE.  135 

and  forty-five  it  is  no  nearer  than  fifteen  inches,  which  is  the 
average  reading  distance.  When  the  near  point  of  accom- 
modation recedes  beyond  this  point  and  vision  is  not  clear 
within  this  limit,  the  condition  becomes  unpleasant  for  read- 
ing, writing,  and  other  near  work,  and  is  known  as  iweshyopui. 
If  a  patient  at  forty-five  can  accommodate  to  a  point  14 
inches  from  the  eyes,  he  has  a  range  of  accommodation  from 
infinity  to  a  distance  of  14  inches,  or  2.75  D.  If  at  fifty  his 
near  point  is  30  inches,  his  range  is  only  1.25  D.,  and  he 
needs  a  lens  to  give  him  the  required  ranges^ — i.  e.y  +1.50  D., 
which  would  make  +2.75  D.,  or  bring  the  near  point  to  14 
inches.  When  he  has  no  accommodation  at  fifty-five,  he 
will  need  +2.75  D.  for  near  work. 

QUESTIONS. 

What  is  a  leas  ?    A  prism  ? 

Describe  four  varieties  of  lenses. 

How  are  lenses  numbered  ? 

Give  rule  for  changing  one  system  into  the  other. 

Describe  the  use  of  the  ophthalmoscope,  retinoscope,  and  ophthalmometer. 

Give  method  of  subjective  examination. 

Define  hypermetropia. 

Explain  the  accommodation. 

What  are  manifest,  total,  and  latent  hypermetropia ? 

Give  tests  for  hypermetropia.     What  is  the  treatment. 

Give  the  definition,  etiology,  complications,  and  treatment  of  mypopia. 

What  is  spasm  of  accommodation? 

Define  astigmatism.    State  varieties  and 

Describe  presbyopia. 


CHAPTER    XX. 
THE  MUSCLES  OF  THE   EYE. 

The  physiologic  action  of  the  external  muscles  of  the  eye- 
ball is  as  follows : 

Internal  rectus  turns  the  eye  inward  (adduction). 

External  rectus  turns  the  eye  outward  (abduction). 

Superior  rectus  turn  the  eye  upward  and  inward  (ad- 
duction), and  rotates  the  upper  extremity  of  the  vertical 
meridian  inward  (wheel  rotation  or  torsion). 


136  THE  MUSCLES  OF  THE  EYE, 

Inferior  rectus  turns  the  eye  downward  and  inward,  and 
rotates  the  upper  end  of  the  vertical  meridian  outward. 

Superior  oblique  rotates  the  upper  end  of  the  vertical 
meridian  inward,  and  turns  the  eye  downward  and  outward. 

Inferior  oblique  rotates  the  upper  end  of  the  vertical 
meridian  outward,  and  turns  the  eye  upward  and  outward. 

The  monocular  ^e/(i  of  fixation  is  the  area  outlined  by  the 
limits  of  movement  of  each  eye  when  the  head  is  at  rest. 

Errors  of  motility  comprise :  I.,  Insufficiency ;  II.,  Stra- 
bismus; and  III.,  Paralysis. 

I.  INSUFFICIENCY. 

Definition. — A  condition  in  which  one  or  more  muscles  are 
lacking  in  power,  but  in  which  binocular  vision  is  main- 
tained in  spite  of  the  error.  There  is  a  tendency  for  the  eyes 
to  deviate,  but  this  is  controlled  by  constant  effort. 

Etiology. — Temporary  depression  in  the  general  health, 
overuse  of  the  eyes,  insufficient  innervation  or  mechanical  dis- 
advantage, such  as  malposition  of  muscular  attachment. 

Varieties. — The  following  terms  are  used  to  describe  the 
varieties  of  insufficiency : 

Orthophoria  is  the  condition  of  normal  balance. 

Hetefrophoria,  imperfect  balance  or  insufficiency. 

Exophoria,  tendency  for  eyes  to  spread.  Insufficiency  of 
the  internal  recti. 

Esophoria,  tendency  to  converge.  Insufficiency  of  the  ex- 
ternal recti. 

Hyperphoria,  tendency  for  eyes  to  deviate  vertically.  In- 
sufficiency of  superior  or  inferior  recti. 

Symptoms. — Pains  in  the  eyes,  headaches,  running  together 
of  print,  diplopia,  dizziness ;  in  general  symptoms  classed 
under  the  head  of  asthenopia. 

Tests. — (a)  Some  patients  with  heterophoria  will  sponta- 
neously or  voluntarily  allow  the  eyes  to  separate  or  many  will 
develop  diplopia  when  a  red  glass  is  held  over  one  eye.  (6) 
Cover-test  (see  p.  31).  (c)  Vertical  diplopia  or  Graefe  test 
consists  in  holding  a  prism  of  8°  or  10°   with  base  down 


STRABISMUS.  137 

over  one  eye.  This  throws  the  image  of  that  eye  upward  over 
the  image  of  the  other.  If  the  lateral  muscles  are  in  equi- 
librium the  upper  image  will  lie  vertically  over  the  other. 
The  amount  of  esophoria  or  exophoria  may  be  measured  by  a 
})rism  Avith  base  out  or  in  which  brings  the  upper  image  over 
the  under  one.  (d)  Adduction  and  Abduction  Tests. — If  a 
prism  is  held  horizontally  over  either  eye  with  the  base  either 
in  or  out  and  eyes  fixed  on  object  twenty  feet  distant,  hori- 
zontal diplopia  will  be  produced  ;  but  if  the  prism  is  not  too 
strong,  the  two  images  will  run  together  and  fuse  into  one. 
The  strongest  prism  with  the  base  in  through  which  the  two 
images  may  be  made  to  fuse  measures  the  fusion  power  of 
the  external  recti  (abduction).  This  should  be  about  7°  or 
8°.  The  strongest  prism  with  base  owf,  through  which  the 
images  fuse,  measures  the  internal  recti  (adduction).  This 
should  be  20°  or  30°.  The  latter  test  is  often  deceptive. 
The  same  method  may  be  used  to  test  the  elevators  and 
depressors  by  holding  the  base  of  the  prism  either  up  or 
down.  Fusion  power  should  be  3°  or  4°.  A  phorometer 
is  an  instrument  constructed  to  hold  suitably  prisms  used  for 
the  tests  just  described. 

Treatment. — Attention  should  be  given  to  the  general 
health.  Errors  of  refraction  should  be  carefully  corrected. 
If  there  is  no  improvement,  so-called  gymnastic  exercises  may 
be  prescribed.  The  patient  practises  by  fusing  the  images 
which  are  produced  by  the  strongest  prism,  making  fusion 
possible,  with  the  base  over  the  muscle  to  be  strengthened. 
The  results  are  sometimes  gratifying,  but  not  likely  to  be 
permanent.  The  constant  use  of  a  prism  as  an  eyeglass  may 
h6  of  value  in  some  cases.  A  prism  of  about  one-half  the 
error,  if  it  is  not  too  great,  is  generally  suitable.  If  the  case 
is  not  improved  by  the  treatment  above  outlined,  faithfully 
carried  out  operative  measures  are  to  considered.  If  the 
external  recti  show  abduction  over  12°  with  weak  adduction, 
the  external  rectus  of  one  eye  may  be  severed  by  a  complete 
tenotomy. 

If  the  external  recti  show  abduction  as  low  as  1°  or  2° 
with  adduction  strong,  th?  internal  rectus  may  be  cut  with 


138  THE  MUSCLES  OF  THE  EYE. 

caution.  If  excessive  effect  is  produced  at  the  time  of  the 
operation,  it  may  be  limited  by  a  suture.  So-called  partial 
tenotomies  consist  in  cutting  a  portion  of  the  tendon.  They 
yield  no  permanent  results. 

n.  STRABISMUS. 

Synonym. — Squint. 

Definition. — A  condition  in  which  both  lines  of  sight  are  not 
directed  toward  the  same  object  of  fixation. 

Varieties. — The  common  varieties  are  convergent  strabismus 
(internal  squint),  where  one  eye  is  turned  inward  toward  the 
nose ;  divergent  strabismus  (external  squint),  one  eye  turns 
outward  toward  the  temple.  Deorsumvergent  strabismus 
(downw^ard)  and  sursimivergent  strabismus  (upward)  are 
uncommon.  A  strabismus  is  said  to  be  concomitant  when  the 
angle  of  deviation  between  the  two  lines  of  sight  remains  the 
same  for  any  point  in  the  field  of  fixation  equally  distant 
from  the  eyes.  Periodic y  when  the  squint  is  not  constant. 
Alternate,  when  either  one  or  the  other  may  be  the  squinting 
eye. 

CONVERGENT  STRABISMUS. 

Etiology. — Generally  appears  between  the  ages  of  two  and 
five.  At  first  periodic,  later  constant.  Hypermetropia  is 
generally  the  refractive  condition  of  the  eyes.  The  squinting 
eye  is  often  amblyopic  (having  poor  vision).  This  is  regarded 
by  some  as  the  result  of  nonuse  (amblyopia  ex  anopsia),  and 
therefore  secondary.  By  others  it  is  considered  a  congenital 
defect,  and  partly  the  cause  of  the  strabismus. 

Symptoms. — The  child  does  not  complain  of  diplopia,  except 
rarely  at  the  beginning,  because  the  image  of  the  squinting 
eye  is  disregarded. 

Tests. — Measurement  of  the  degree  of  squint  may  be 
made  by  noting  the  distance  on  the  lower  lid  at  which  the 
centre  of  the  cornea  lies  from  the  place  which  corresponds  to 
that  of  the  other  eye.  The  angular  deviation  may  also  be 
measured  by  means  of  the  reflex  from  the  cornea  by  passing 
a  candle  along  the  arc  of  a  perimeter. 


DIVERGENT  STRABISMUS.  139 

Treatment. — Nonoperative. — Convergent  strabismus  may  be 
treated  in  very  young  children  when  it  first  appears  by  placing 
a  cover  over  the  better  eye  and  forcing  the  child  to  use  the 
squinting  eye.  It  is  important,  when  the  child  is  old  enough, 
that  glasses  should  be  worn  to  correct  fully  the  errors  of  refrac- 
tion. There  is  usually  hyperopia,  or  hyperopic  astigmatism. 
Under  such  treatment  a  number  of  cases  will  recover. 

Operative  treatment  consists  in  performing  tenotomy  of 
the  internal  rectus  of  one  or  both  eyes,  and  sometimes  an 
advancement  of  the  external  rectus. 

Tenotomy. — The  conjunctiva  over  the  insertion  of  the  ten- 
don is  seized  with  a  toothed  forceps  about  7  mm.  from  the 
edge  of  the  cornea.  A  small  opening  is  made  with  the  scis- 
sors, exposing  Tenon's  capsule.     This  is  opened  in  a  similar 

Fig.  33. 


Tenotomy  of  an  ocular  muscle.    (Veasey.) 

manner,  and  the  tendon  may  then  be  caught  up  by  passing  a 
strabismus  hook  beneath  it.  The  tendon  should  be  completely 
cut  close  to  the  eyeball.  A  suture  may  be  used  to  bring  together 
the  edges  of  the  conjunctival  wound.  The  opening  in  the 
conjunctiva  and  capsule  is  sometimes  made  at  the  edge  of  the 
tendon  and  the  muscle  cut  by  passing  the  scissors  underneath 
the  conjunctiva  (subconjunctival  tenotomy).  The  eifect  of  a 
tenotomy  upon  a  squint  is  not  always  easy  to  predict  with 
certainty.     Remembering,  however,  that  the  edge  of  the  cor- 


140  THE  MUSCLES  OF  THE  EYE. 

nea  should  normally  turn  on  either  side  to  the  inner  and 
outer  canthus,  any  decrease  or  increase  of  motility  can  be 
estimated.  Such  indications  are  the  best  guides  for  operation. 
If  tenotomy  of  the  internal  rectus  of  the  squinting  eye  does 
not  produce  sufficient  effect,  the  other  eye  may  be  operated 
upon  after  waiting  at  least  two  months.  At  times,  wlien  the 
motility  of  the  squinting  eye  is  markedly  deficient  outward, 
advancement  (see  p.  137)  of  the  internal  rectus  is  indicated. 
As  there  is  a  tendency  toward  divergence  in  later  years,  it  is 
safer  to  leave  a  little  convergence. 

DIVERGENT  STRABISMUS. 

Etiology. — May  appear  at  any  age.  Often  associated  with 
myopia.  Found  after  loss  of  vision  in  an  eye  from  injury  or 
disease  and  after  faulty  operation  for  convergent  strabismus. 

Treatment. — In  the  majority  of  cases  tenotomy  of  the 
external  rectus  will  not  suffice,  but  an  advancement  of  the 
internal  rectus  is  necessary  in  connection  with  it. 

Advancement. — The  tendon  of  the  opposing  muscle  is  first 
cut.  An  incision  is  made  over  the  tendon,  and  sometimes  an 
elliptical  piece  of  conjunctiva  is  excised.  Tenon's  capsule, 
thus  exposed,  is  opened  and  the  muscle  raised  upon  two  hooks. 
One  suture  is  passed  through  the  conjunctiva  on  the  side  of 
the  wound  farthest  from  the  cornea,  then  through  the  middle 
of  the  muscle  about  ^  inch  or  more  from  its  insertion.  Two 
other  sutures  are  then  passed,  one  below  and  one  above.  The 
tendon  is  severed  from  its  attachment  to  the  eyeball  and  a 
piece  cut  off  nearly  down  to  the  sutures.  The  first  suture  is 
then  passed  in  a  horizontal  line  under  the  conjunctiva  on  the 
corneal  side,  taking  a  firm  hold  on  the  episcleral  tissue  and 
coming  out  near  the  cornea.  The  other  two  are  passed  in  the 
same  way  above  and  below.  The  sutures,  when  tied,  will 
advance  the  muscle  to  produce  the  effect  desired.  Sutures 
should  be  left  in  place  about  seven  days. 


PAUALtStS  OF  m^  OCULAR  MtlSCLES.  l4l 

ra.  PARALYSIS  OP  THE   OCULAR  MUSCLES. 

Varieties. — Classification  may  be  (a)  according  to  the  nerve 
affected.  Tiie  third  nerve  supplies  all  the  muscles  (including 
the  sphincter  pupillse,  ciliary  muscle,  and  levator  palpebrse) 
except  the  external  rectus  and  superior  oblique,  which  are 
supplied  by  the  sixth  and  fourth  respectively;  (6)  according  to 
the  muscle  paralyzed. 

Internal  ophthalmoplegia  is  a  term  used  to  designate  par- 
alysis of  the  intrinsic  muscles,  the  sphincter,  and  ciliary 
muscle;  and  external  ophthalmoplegia,  paralysis  of  the  ex- 
trinsic muscles ;  total  ophthalmoplegia,  when  both  inti'insiG 
and  extrinsic  muscles  are  paralyzed. 

Etiology. — Paralysis  may  be  congenitaly  especially  of  the  ex- 
ternal rectus  and  levator  palpebrae  (ptosis).  In  the  acquired 
form,  syphilis  is  the  most  common  cause.  Other  causes  are 
traumatism,  locomotor  ataxia,  tumors,  hemorrhages,  and  toxic 
conditions. 

Pathology. — The  paralysis  may  be  cortical,  nuclear,  in  the 
nerve-trunk,  or  peripheral. 

Subjective  Symptoms. — The  patient  suffers  most  from  dip- 
lopia, dizziness,  and  confusion  of  vision. 

Objective  Symptoms. — The  excursion  of  the  affected  eye 
is  limited.  The  head  is  held  habitually  away  from  the 
side  of  the  paralyzed  muscle  in  order  to  avoid  diplopia. 
The  character  of  the  diplopia  may  be  tested  as  follows :  A 
red  glass  is  placed  over  the  paralyzed  eye.  The  red  image  is 
called  the  false  image.  The  false  image  appears  to  the  patient 
to  occupy  a  position,  relative  to  the  true  image,  which  repre- 
sents the  physiologic  action  of  the  muscle  paralyzed.  For 
example  :  if  the  right  external  rectus  is  paralyzed,  there  will 
be  diplopia  to  the  right  of  the  median  line,  and  the  image  of 
that  eye  will  be  to  the  right  and  on  a  level  with  the  other 
image,  which  represents  the  action  of  the  right  external 
rectus — i.  e.,  turning  the  eye  to  the  right  horizontally.  The 
above  rule  will  be  found  applicable  to  all  cases  except  where 
secondary  contractions  have  taken  plnce 

Treatment. — In    syphilitic   cases    mercury   and   iodide   of 


142  THE  MUSCLES  OF  THE  EYE, 

potassium  should  be  given  in  full  doses.  In  other  cases 
sodium  salicylate,  mercury,  iodide  of  potassium,  and  strych- 
nine. Sometimes,  in  mild  cases,  wearing  of  a  prism  will 
help  to  fuse  the  images.  At  times  a  cover  must  be  worn 
over  the  paralyzed  eye.     Operations  are  usually  unsatisfactory. 


NYSTAGMUS. 

Definition. — An  involuntary  oscillatory  movement  of  the 
eyeball,  usually  from  side  to  side  (lateral  nystagmus),  occa- 
sionally up  and  down  (vertical),  or  with  wheel  rotation  (rotary). 

Etiology. — The  condition  is  usually  congenital  and  associated 
with  poor  vision.  It  is  sometimes  acquired  when  the  eyes 
are  used  under  poor  illumination  (miners'  nystagmus). 

Treatment. — There  is  no  treatment  for  the  former.  For 
the  latter,  change  of  occupation. 

QUESTIONS. 

What  is  the  physiologic  action  of  each  of  the  ocular  muscles? 
Define  insufiiciency,  and  give  terms  used  to  describe  varieties. 
Name  four  tests  for  heterophoria. 
Give  the  treatment  for  heterophoria. 
What  are  the  common  varieties  of  strabismus  ? 

Give  the  cause,  etiology,  symptoms,  and  treatment  of  convergent  stra- 
bismus. 

Describe  operations  for  tenotomy  and  advancement. 
How  may  paralysis  be  classified  ? 
Give  rule  for  determining  the  muscle  affected. 
What  is  nystagmus? 


^  JOHN  K.  MORRIS,  M.  fX 
THE  EAR  AND  ITS  DISEASES. 


CHAPTER  I. 
ANATOMY   AND  PHYSIOLOGY. 

For  the  convenience  of  study  the  organ  of  hearing  may  be 
considered  as  being  composed  of  (1)  a  conducting  apparatus — 
consisting  of  the  auricle,  external  auditory  meatus,  merabrana 
tympani,  ossicles,  and  the  tympanum,  together  with  the  con- 
necting cavities  of  the  Eustachian  tube  and  the  mastoid 
process — by  means  of  which  certain  forms  of  ethereal  vibra- 
tions are  collected  and  transmitted  inward  to  (2)  a  perceptive 
mechanism — divided  into  the  vestibule,  semicircular  canals, 
and  cochlea,  with  its  filamentous  terminations  of  the  auditory 
nerve — through  the  agency  of  which  the  vibrations  are  recog- 
nized and  the  resulting  stimulation  is  conveyed  to  the  audi- 
tory centre  of  the  brain  and  there  interpreted  as  sound. 

A  further  clinical  subdivision  considers  the  conducting 
portion  as  being  composed  of  an  external  ear  (auricle  and  ex- 
ternal auditory  meatus),  a  middle  ear  (membrana  tympani, 
ossicles,  and  the  tympanic  cavity,  with  its  connecting  Eu- 
stachian tube  and  mastoid  process),  while  the  perceptive 
mechanism  constitutes  the  internal  ear  or  labyrinth. 

THE  CONDUCTING  APPARATUS. 

The  External  Ear. 

The  Auricle. — To  secure  the  best  concentration  and  con- 
duction of  the  sound-waves,  the  external  ear  is  an  oval, 
funnel-shaped  organ  with  the  convexity  of  the  auricle  point- 

143 


144  ANATOMY  AND  PHYStOLOGT. 

ing  inward  toward  the  middle  ear  or  tympanum.  In  struct- 
nre,  with  the  exception  of  the  lobule  (Fig.  33),  which  is 
composed  of  a  network  of  connective  tissue  interposed  with 
globules  of  fat,  the  auricle  or  pinna  consists  of  a  convoluted, 
cartilaginous  framework,  attached  to  the  temporal  bone  by 
ligaments  and  rudimentary  muscles,  and  covered  by  a  thin, 
firmly  adherent  reflection  of  the  integument  from  the  side  of 
the  head,  preserving  the  ridges  and  depressions  of  the  sub- 

Fig.  33. 


Auricle :  A,  helix ;  B,  antihelix  ;  C,  tragus ;  D,  antitragus  ;  E,  lobule ;  F,  concha : 
G,  orifice  of  the  external  meatus.    (Politzer.) 

structure,  which  are  named  as  indicated  in  the  accompanying 
illustration. 

The  external  auditory  meatus  is  a  canal,  which  leads  from 
the  concha  inward  about  one  inch  and  a  quarter,  termi- 
nates with  a  membrane  which  separates  the  external  ear 
from  the  tympanic  cavity  (Fig.  34).  The  outer  third  of  this 
passage,  which  is  a  prolongation  inward  of  the  auricle,  is 
cartilaginous,  and  forms  an  angle  with  the  inner  portion, 
which  is  bony  in  the  adult.     Hence,  the  auricle  must  be  pulled 


TME  MIDDLE  EAR  145 

upward,  hachwardy  and  outward  to  make  the  meatus  straight, 
when  examming  the  intenor  of  the  canal  or  the  terminating 
membrane.  The  inner  two-thirds  of  the  meatus  is  mem- 
branous in  the  infant,  with  the  exception  of  the  distal  end, 
which  is  formed  by  a  bony  ring,  the  annulus  tsrmpanicus, 
which  with  development  gradually  elongates  outward,  replac- 
ing the  membranous  passage  and  forming  the  osseous  portion 
of  the  adult  ear,  which  is  about  three-quarters  of  an  inch  in 
length.  A  prolongation  inward  of  the  skin  of  the  auricle 
forms  the  lining  membrane  of  the  meatus,  which  is  thin  and 
firmly  attached  in  the  bony  portion.  In  the  cartilaginous 
part  numerous  hairs,  together  with  sebaceous  and  ceruminal 
glands,  are  present,  which  normally  prevent  to  a  marked 
extent  the  entrance  or  retention  of  foreign  bodies  within  the 
canal. 

The  blood-supply  of  the  auricle  and  the  outer  end  of  the 
meatus  is  derived  from  the  superficial  temporal  and  the  pos- 
terior auricular  arteries,  while  the  bony  portion  of  the  canal 
is  supplied  with  branches  from  the  internal  maxillary. 

The  nerve  distribution  of  the  auricle  is  from  the  deep  poste- 
rior auricular  and  auricularis  magnus,  while  that  of  the  ex- 
ternal auditory  meatus  is  derived  mainly  from  the  auriculo- 
temporal branch  of  the  inferior  maxillary  nerve. 

THE  MIDDLE  EAR. 

The  Membrana  Tympani. — Situated  at  the  inner  end  of  the 
external  auditory  meatus,  and  separating  it  from  the  tympanic 
cavity,  is  a  pearly- gray,  oval-shaped  membrane,  concave  on 
its  outer  surface,  and  placed  obliquely  to  the  axis  of  the  canal 
so  that  the  upper  and  posterior  portion  is  the  least  removed 
from  the  examiner  (Fig.  34).  Its  structure  consists  of  an 
outer  dermal  surface  continuous  with  that  of  the  meatus,  a 
middle  fibrous  membrane,  and  an  inner  mucous  covering, 
which  is  reflected  from  the  lining  membrane  of  the  tympanum. 
Within  these  layers  rests  the  long  handle  of  the  malleus,  the 
outlines  of  which  are  faintly  followed  from  above,  downward, 
and  backward  to  its  termination  at  the  centre  of  the  mem- 

10— E.  E. 


146 


ANATOMY  AND  PHYSIOLOGY. 


brana  tympani  in  a  slight  depression,  umbo,  from  which 
point  a  triangular,  glistening  area  projects  downward  and  for- 
ward to  the  periphery  of  the  membrane  (Fig.  35).  This  cone 
of  light,  as  it  is  termed,  is  a  reflection  of  the  rays  from  the 
surface  of  the  membrana  tympani,  due  to  its  smoothness, 
obliquity  of  position,  and  contour  of  surface.     At  the  upper 

Fig.  34. 


Incus. 
\ 

I  Malleus. 
I  ' 
,  \Slapes. 

^-.< — Semi-circular  CanaU. 
Vestibule. 
Cochlea. 


A  front  view  of  the  organ  of  hearing  (right  side).    (Gray.) 


end  of  the  handle  is  observed  a  yellowish-white  projection, 
short  handle  of  the  malleus,  from  which  point  thin  folds  of 
membrane  pass  antra-supra-posteriorly  to  the  upper  wall  of 
the  canal,  constituting  the  membrana  flaccida  or  Shrapnell's 
membrane.  The  membrana  tympani  not  only  serves  as  a 
protection  to  the  delicate  structures  within  the  tympanum, 
but  also  receives  the  sound-vibrations  from  without  and  trans- 
mits them  to  the  ossicular  chain  of  the  middle  ear. 


THE  MIDDLE  EAB. 


147 


The  Tympanum. — Just  beyond  the  membrana  tjmpani, 
which  forms  the  greater  part  of  its  outer  wall,  is  situated, 
within  the  petrous  portion  of  the  temporal  bone,  the  tym- 
panum, an  irregular  cavity  having  its  greatest  diameters 
antra-posteriorly  and  supra-inferiorly,  with  an  inward  depth 
of  about  one-eighth  of  an  inch  to  the  promontory  from  the 
drum  membrane  (Fig.  36).     The  upper  portion  of  this  cav- 

FiQ.  35. 


The  normal  membrana  tympani  (right  ear) :  1,-membrana  flaccida ;  2,  long  handle ; 
3,  cone  of  light ;  4,  membrana  vibrans ;  5,  umbo ;  6,  short  handle. 


ity,  the  attic,  lies  immediately  below  the  middle  lobe  of  the 
brain,  separated  from  it  by  a  thin  layer  of  bone,  which  forms 
the  roof  of  the  tympanum.  The  lower  portion  of  the  tym- 
panic cavity  is  termed  the  atrium.  The  floor,  narrower  than 
the  roof  and  pierced  by  the  Jacobson  nerve,  rests  just  above 
the  jugular  fossa.  The  outer  wall,  formed  largely  by  the 
membrana  tympani  and  the  annulus  tympanicus,  into  which 
bony  ring  the  membrane  is  inserted,  contains  the  Glaserian 
fissure,  the  iter  chordae  posterius,  and  the  iter  chordae  ante- 
rius,  the  latter  two  being  the  openings  through  which  the 
chorda  tympani  nerve  enters  and  emerges  from  the  tympanic 


148 


ANATOMY  AND  PHYSIOLOGY, 


cavity  in  its  course  across  the  inner  surface  of  the  drum  mem- 
brane between  the  long  handles  of  the  malleus  and  incus 
(Fig.  36)  on  its  way  to  the  submaxillary  gland. 

Separating  the  tympanum  from  the  internal  ear,  the  inner 


The  middle  and  internal  ear :  1,  membrana  tympani ;  2,  long  process  of  malleus : 
3,  chorda  tympani  nerve ;  4,  short  process  ;  5,  tendon  of  tensor  tympani  muscle ; 
6,  malleus ;  7,  ligament ;  8,  attic ;  9,  incus ;  10,  facial  nerve  ;  11,  vestibule ;  12,  stapes  ; 
13,  auditory  nerve ;  14,  Eustachian  tube ;  15,  cochlea ;  16,  promontory ;  17  atrium 
(right  ear,  anterior  view). 

wall  presents  the  following  points  of  interest,  as  illustrated  in 
Fig.  37  : 

(1)  The  fenestra  ovalis,  which  opens  into  the  vestibule  of 
the  internal  ear,  but  is  occupied,  in  the  recent  state,  by  the 
foot-plate  of  the  stapes  (Fig.  37). 

(2)  The  fenestra  rotundum,  closed  by  a  thin  membrane 
(membrana  tympani  secondaria),  beyond  which  lies  the  cavity 
of  the  scala  tympani  of  the  cochlea. 

(3)  The  promontory,  a  convexity  of  the  inner  wall,  formed 


THE  MIDDLE  EAR. 


149 


by  the  first  turn  of  the  cochlear  spiral,  which  is  situated  just 
beyond  the  inner  wall  (Fig.  36). 

(4)  The  Aquaeductus  Fallopii,  a  small  canal  through  which 
the  facial  nerve  passes,  marked  by  a  bony  ridge  along  the 
supraposterior  part  of  the  inner  wall. 

(5)  The  Pyramid,  a  bony,  cone-shaped  projection,  which 
contains  the  stapedius  muscle. 


Fig.  37. 


Chorda  tympani 


View  of  inner  wall  of  tympanum  (right  ear).    (Gray.) 

The  anterior  wall,  which  is  interposed  between  the  carotid 
canal  and  the  tympanum,  presents  the  tympanic  orifice  of  the 
Eustachian  tube,  canal  for  the  tensor  tympani,  and  the  proc- 
esses cochleariformis,  which  is  a  thin,  bony  partition  separating 
the  two  canals,  while  the  posterior  wall,  which  has  the  greatest 
height,  reveals  in  its  upper  portion  a  passage,  antrum,  through 
which  the  vault  of  the  tympanum,  attic,  communicates  with 
the  cells  of  the  mastoid  process,  situated  posteriorly. 

The  Ossicles. — Connecting  the  membrana  tympani  with  the 
fenestra  ovalis  of  the  inner  wall,  an  ossicular  chain,  consisting 
of  the  malleus,  incus,  and  stapes,  serves  to  transmit  the  vibra- 
tions imparted  to  the  drum  membrane  across  the  tympanic 
<5avity  to  th^  labyrinth  or  intern^  e^r.    Fig,  38  illustrates 


150  ANATOMY  AND  PHYSIOLOGY. 

very  well  the  general  shape,  relative  size,  and  position  of  the 
bones. 

The  malleus  consists  of  (1)  a  headj  which  articulates  with 
the  incus  ;  (2)  a  neckj  constricted  portion  below  the  head  ;  (3) 
a  long  process,  handle  or  manubrium,  which  is  embedded  in  the 
layers  of  the  membrana  tympani ;  (4)  a  short  process,  processus 
brevis,  which  presents  at  the  upper  end  of  the  manubrium  ; 
and  (5)  a  processus  gracilis,  which  lies  in  the  Glaserian  fissure. 

Fig.  38. 


ocessus  brevis. 


■  Os  orbiculare. 

Head, 
Crura. 
The  small  bones  of  the  ear,  seen  from  the  outside.    (Gray.) 

The  incus,  which  resembles  in  outline  a  molar  tooth,  has  (1) 
a  body,  which  articulates  with  the  malleus ;  (2)  a  long  process, 
which  articulates  with  the  head  of  the  stapes;  (3)  a  short 
process,  which  has  a  ligamentous  attachment  at  the  lower  edge 
of  the  antrum  on  the  posterior  wall  of  the  tympanum. 

The  stapes,  as  its  name  indicates,  is  stirrup-shaped,  and 
presents  (1)  a  head,  which  articulates,  as  shown  above ;  (2)  a 
foot-plate,  which  occupies,  in  the  recent  state,  the  fenestra 
ovalis,  being  attached  to  the  surrounding  bony  wall  by  an 
intervening  annular  ligament ;  and  (3)  the  crura,  which  con- 
nect the  head  and  the  foot-plate. 

The  Joints  and  Ligaments  of  the  Ossicles. — The  ossicles  are 
held  in  articulation  and  suspension  within  the  tympanic  cavity 
by  means  of  ligaments,  which,  however,  permit  freedom  of 
ossicular  vibration  in  the  normal  state  ;  but  in  certain  diseased 
conditions  the  ligaments  about  the  articulations  become  thick- 
ened^ so  that  the  joints  assume  o,  stifFefte(}  or  ^v^n  ankj^lose^ 


THE  MIDDLE  EAR. 


151 


condition,  which  interferes  markedly  with  the  ease  of  mobility, 
thus  lowering  the  function  of  hearing  even  to  inaudition  if 
the  process  be  sufficiently  extensive. 

The  Eustacliian  Tube.— With  an  opening  in  the  anterior  wall 


Fig.  39. 


G  H  I  A 

Eustachian  tube  and  tympanic  cavity  (right  ear,  viewed  from  within):  A,  mem- 
brana  tyrapani ;  B,  head  of  the  malleus  ;  C,  lower  end  of  the  handle  of  the  malleus  : 
D,  body  of  the  incus ;  E,  .short  process  of  the  incus ;  F,  tensor  tympani  muscle ; 
G,  pharyngeal  opening  of  the  tube;  H,  isthmus  of  the  tube;  I,  tympanic  opening 
of  the  tube.    (Politzer.) 

of  the  tympanum  (Fig.  89),  an  osseous  canal  passes,  from  this 
point,  inward,  forward,  and  downward  through  the  petrous 
bone,  when  it  merges  into  a  cartilaginous  canal,  which  termi- 
nates in  a  funnel-shaped  protuberance,  with  a  slit-like  orifice, 


152  ANATOMY  AND  PHYSIOLOGY. 

located  in  the  nasopharynx,  just  back  of  the  inferior  turbinated 
body  (Fig.  53).  At  the  junction  (isthmus)  of  the  cartilaginous 
and  osseous  portions,  the  canal  has  a  diameter,  in  the  recent 
state,  of  about  one-twelfth  of  an  inch,  which  gradually  increases 
toward  the  tympanic  and  pharyngeal  ends,  where  it  measures 
one-eighth  to  one-quarter  of  an  inch,  the  slit-shaped  orifice  of  the 
latter  being  greatest  in  the  vertical  direction.  This  condition 
results  from  the  fact  that  the  cartilaginous  portion,  which  forms 
the  inner  two-thirds  of  the  Eustachian  tube,  is  not  composed 
throughout  of  cartilage ;  the  lower  two-thirds  of  the  anterior 
wall,  together  with  all  of  the  inferior,  is  membranous,  inter- 
mingled with  muscular  fibres  of  the  tensor  palati.  Hence,  the 
slit-shaped  lumen  of  the  cartilaginous  portion  of  the  tube  is 
normally  obliterated  in  most  cases  through  contact  of  the 
anterior  membranous  wall  with  that  of  the  posterior,  excepting 
the  upper  portion  of  the  lumen,  which  remains  patent  because 
of  its  cartilaginous  wall,  thus  preserving  the  passage  at  this 
point,  though  it  may  be  obliterated  by  an  inflammatory  sw^ell- 
ing  of  the  lining  mucous  membrane.  During  the  act  of  swal- 
lowing, the  tensor  palati  and  the  levator  palati  muscles  open 
the  pharyngeal  portion  of  the  Eustachian  tube  by  drawing  the 
anterior  membranous  wall  forward  and  elevating  the  inferior 
portion  of  the  tube,  which  acts  increase  the  antra-posterior 
diameter  of  the  passage  and  permit  the  entering  air  to  reach 
the  tympanic  cavity,  thus  equalizing  the  atmospheric  pressure 
upon  the  internal  and  outer  surfaces  of  the  membrana  tym- 
pani,  and  favoring  its  freedom  of  vibration. 

The  Lining  Membrane  of  the  Middle  Ear. — The  mucous  mem- 
brane of  the  tympanum,  which  is  continuous  with  that  of 
the  nasopharynx  through  the  Eustachian  tube,  is  thin,  cili- 
ated, and  slightly  vascular  in  character.  It  not  only  forms  the 
lining  investment  of  the  tympanic  cavity,  but  also  extends  to 
the  spaces  of  the  mastoid  process  through  the  intervening 
antrum,  and  forms  a  covering  of  the  ossicles,  intratympanic 
muscles,  and  ligaments.  The  resulting  reduplications  or 
folds  of  the  mucous  membrane  are  of  special  interest  in  in- 
flammatory conditions  of  the  tympanum,  and  especially  those 
in  th^  at^iCj  which  ^re  large  an^  numerous,  as  thej^  form  yery 


THE  CUDDLE  EAR.  153 

favorable  conditions  for  the  development  and  retention  of  an 
infective  process,  as  will  be  shown  later.  In  the  tympanic 
})ortion  of  the  Eustachian  tube  the  lining  membrane  is  also 
thin,  smooth,  ciliated,  and  firmly  adherent,  while  in  the  car- 
tilaginous extremity  it  assumes  the  thick,  vascular,  and  loosely 
attached  character  of  the  nasopharyngeal  mucous  membrane, 
through  which  route  inflammatory  conditions  of  the  latter 
frequently  extend  to  the  tympanic  cavity. 

The  Intratympanic  Muscles. — Only  two  muscles,  the  tensor 
tympani  and  the  stapedius,  are  present  within  the  ear.  The 
tensor  tympani  (Fig.  36)  obtains  its  origin  from  the  upper  wall 
of  the  Eustachian  tube  and  the  sides  of  the  canal  through  which 
it  passes ;  emerges  from  the  orifice  of  its  canal  just  above  the 
Eustachian  opening ;  curves  around  the  projecting  processus 
cochleariformis  at  nearly  a  right  angle  ;  crosses  the  tympanic 
cavity  ;  and  makes  its  attachment  to  the  inner  border  of  the 
long  handle  of  the  malleus  just  below  the  neck.  The  stapedius 
muscle  originates  within  the  bony  canal  of  the  pyramid  (Fig. 
37),  and  forms  an  insertion  into  the  neck  of  the  stapes  through 
an  intervening  tendon. 

The  action  of  the  tensor  tympani  alone  draws  the  drum 
membrane  inward,  thus  rendering  it  more  taut,  and  also 
forces  the  foot-plate  of  the  stapes  inward,  thereby  increasing 
the  intralabyrinthine  pressure,  while  the  action  of  the  stape- 
dius muscle  is  antagonistic  to  the  action  of  the  former,  as  it 
tends  to  draw  the  foot-plate  outward,  the  posterior  margin 
serving  as  a  fulcrum,  thus  lessening  the  labyrinthine  tension. 
It  is  therefore  probable  that  the  function  of  these  muscles 
is  to  preserve  an  uniformity  of  pressure  within  the  labyrinth 
under  the  varying  conditions  of  atmospheric  force  and  inten- 
sity of  sound. 

The  Arteries. — The  blood-supply  of  the  tympanum  is  derived 
mainly  from  (1)  the  tympanic  branch  of  the  internal  maxil- 
lary, which  enters  the  cavity  through  the  Glaserian  fissure, 
supplying  the  anterior  wall  and  the  tympanic  end  of  the 
Eustachian  tube,  and  anastomosing  at  the  periphery  of  the 
membrana  tympani  with  the  stylomastoid  branch  of  the  pos- 
terior auricular ;  (2)  the  superficial  petrosal  from  the  middle 


154 


ANATOMY  AND  PHYSIOLOGY. 


meningeal,  which  reaches  the  attic  through  the  petrosquamous 
suture,  and  is  distributed  to  the  roof  of  the  tympanum,  the  mal- 
leus and  incus,  and  the  inner  wall  through  which,  according 
to  Pulitzer,  "vascular  connections  are  kept  up  between  the 
middle  ear  and  the  labyrinth'^ ;  (3)  the  tympanic  branch  of  the 
internal  carotid,  which  anastomoses  with  the  tympanic  and 
Vidian  branches  of  the  internal  maxillary  upon  the  floor  and 
inner  wall  of  the  tympanum.  In  addition  to  the  supply 
indicated  above,  the  Eustachian  tube  receives  the  pharyngeal 

Fig.  40. 


Vertical  (sagittal)  section  of  the  mastoid  process  and  the  osseous  meatus :  a,  mas- 
toid cells  ;  6,  posterior  wall  of  the  osseous  meatus ;  c,  anterior  wall  of  the  osseous 
meatus.    (Politzer.) 


branch  of  the  external  carotid,  a  few  small  branches  from  the 
internal  carotid,  and  the  descending  palatine  and  pterygo- 
palatine branches  of  the  internal  maxillary  artery. 

The  Nerves. — Through  the  otic  ganglion  the  trifacial  sup- 
plies the  tensor  tympani,  a  filament  from  the  facial  innervates 
the  stapedius  muscle,  while  the  lining  membrane  of  the  tym- 
panum and  the  Eustachian  tube  receives  its  supply  from  the 
tympanic  plexus. 

Trie  Mastoid  Process. — Immediately  behind  the  auricle  (ind 


THE  PERCEPTIVE  MECHANISM.  155 

somewhat  inferiorly  is  located  a  large,  rounded,  bony  pro- 
tuberance, at  the  lower  tip  of  which  the  sternocleidomastoid 
muscle  forms  an  attachment.  Its  inward  structure  is  usually 
composed  of  a  varying  number  of  pneumatic  spaces  or  cells, 
irregular  in  size  and  shape  (Fig.  40),  which  freely  communi- 
cate with  each  other  through  openings  in  their  intervening 
walls  and  also  with  the  tympanic  cavity  through  the  antrum. 
Some  mastoids  are  formed  almost  entirely  of  air-cavities,  while 
others  contain  but  few  or  no  spaces,  which  is  usually  true  of 
the  infantile  process,  but  with  development  the  chambers  are 
gradually  formed  and  enlarged.  In  the  child  the  inner  wall 
of  the  mastoid,  which  separates  the  air-cavities  from  the 
lateral  or  sigmoid  sinus  of  the  brain,  is  quite  thick,  while  the 
opposite  outer  wall  is  thin  and  often  imperfect.  Hence,  in- 
flammatory conditions  within  the  mastoid  rarely  extend  in- 
ward to  the  meninges  in  the  youthful  patient,  but  tend  to 
pass  outward  through  the  opposite  wall,  a  circumstance  which 
is  indeed  fortunate.  The  anatomical  conditions  are  reversed 
in  the  adult,  though  the  firmer  and  harder  structures  form  a 
strong  barrier  to  the  passage  of  infection  inward.  Since  the 
mucous  membrane  lining  the  pneumatic  spaces  of  the  mastoid 
is  continuous  with  that  of  the  tympanic  cavity  through  the 
antrum,  infective  processes  of  the  tympanum  frequently  ex- 
tend backward  and  involve  the  chambers  of  the  mastoid 
process. 

The  lateral  sinus,  which  courses  along  the  inner  wall  of  the 
mastoid,  the  meninges  of  the  brain,  which  are  separated  from 
the  antrum  by  only  a  thin  lamina  of  bone,  and  the  facial 
nerve  in  its  passage  through  the  aquaeductus  Fallopii,  are 
structures  of  special  importance  to  be  considered  in  inflamma- 
tory conditions  and  surgical  procedures. 


THE  PERCEPTIVE  MECHANISM. 

The  Internal  Ear. 

Just  beyond  the  inner  wall  of  the  tympanum  a  group  of 
osseoqs  cavities  and  curving  canals  receive  the  peripheral  enc}-? 


156  ANATOMY  AND  PHYSIOLOGY. 

organs  of  the  auditory  nerve  through  which  the  sound-vibra- 
tions imparted  from  without  are  recognized  and  conveyed  to 
the  brain.  This  labyrinth,  so  termed  from  its  complexity  of 
shape,  consists  of  an  osseous  portion  (vestibule,  semicircular 
canals,  and  cochlea)  within  which  a  membranous  portion 
(utricle,  saccule,  semicircular  passages,  and  scala  media), 
filled  with  a  fluid,  forms  a  loose  inner  lining,  being  separated 
from  the  bony  walls  by  an  intervening  perilymph. 

The  Bony  Labyrinth. 

The  Vestibule. — This  cavity,  which  forms  the  greater  part 
of  the  internal  aural  chamber,  is  an  oval,  bony  space  about 
one-quarter  of  an  inch  in  diameter,  and  is  situated  imme- 
diately beyond  the  internal  wall  of  the  middle  ear,  with  which 
it  communicates  in  the  late  state  through  the  fenestra  ovalis. 
The  anterior  part  of  the  inner  wall  of  the  vestibule  presents 
above  an  oval  depression,  fovea  hemi-elliptica,  and  below,  a 
small  round  excavation,  fovea  hemispherica,  into  which  fila- 
ments of  the  auditory  nerve  enter  through  minute  foramina 
in  the  inner  wall,  while  the  posterior  portion  of  the  vestibular 
cavity  reveals  the  aquseductus  vestibuli,  which  passage  con- 
nects with  the  subdural  space.  In  front  the  vestibule  be- 
comes the  scala  vestibuli  of  the  cochlea  (Fig.  41),  while  pos- 
teriorly the  semicircular  canals  communicate  with  the  vestibule 
by  five  openings. 

The  Semicircular  Canals. — Three  small  bony  passages  emerge 
from  the  posterior  aspect  of  the  vestibule,  follow  a  nearly 
circular  course  through  the  osseous  tissue,  and  terminate 
in  a  dilated  portion,  ampulla,  where  they  again  commu- 
nicate with  the  cavity.  One  of  the  canals  passes  upward,  and 
is  termed  the  superior  semicircular  canal ;  another,  the  poste- 
rior semicircular  canal,  runs  both  vertically  and  backward ; 
while  the  shortest  of  the  three,  the  external  semicircular 
canal,  takes  an  outward  and  backward  course.  The  former 
canals  possess  at  one  end  a  common  opening  into  the  ves- 
tibular chamber. 

The  Cochlea, — Situated  antra-inferiorly  to  th^  v^stibule^  with 


^tni:  PERCEPTIVE  mechanism.  16? 

which  it  communicates,  and  internally  to  the  promontory 
which  is  formed  by  its  first  turn,  a  spiral  canal,  which  re- 
sembles that  of  a  minute  snail-shell,  is  formed  in  the  petrous 
bone,  constituting  the  cochlea  (Fig.  42).  It  consists  of  a 
conical  central  axis,  the  modiolus,  around  which  a  tapering 
spiral  canal  makes  two  and  one-half  turns,  ending  in  an  apex 
which  points  outward  and   forward,  while  the  base  of  the 

Fig.  41. 


Opening  of  aqueductus  vestibuli. 
Bristle  passed  through  foramen  rotunduni. 

Opening  of  aqueductus  cochleae. 
The  osseous  labyrinth  laid  open  (right  ear).    (Gray.) 

cochlea  faces  the  internal  auditory  meatus.  Winding  around 
the  modiolus  from  the  base  to  its  apex,  a  thin  bony  plate, 
lamina  spiralis  ossea,  projects  from  the  central  axis  outward, 
midway  across  the  lumen  of  the  canal  (Fig.  44),  where  it  joins, 
on  its  lower  edge,  a  lamina  spiralis  membranosa  or  membrana 
basilaris  from  the  opposite  side,  thus  dividing  the  spiral  canal 
into  two  passages — the  scala  vestibuli  above  and  the  scala  tym- 
pani  inferiorly,  which  communicate  at  the  apex  of  the  cochlea 


158 


ANATOMY  AND  PHYSIOLOGY. 


through  a  small  foramen.  The  former  passage  enters  the 
vestibule,  Avhile  the  latter  communicates  with  the  tympanum 
in  the  late  stage  through  the  fenestra  rotundum,  which  is 
normally  occupied  by  the  membrana  tympani  secondaria. 
Through  several  canals  in  the  base  of  the  modiolus,  blood-ves- 
sels and  bundles  of  the  cochlear  branch  of  the  auditory  nerve 
are  distributed  to  the  scalae.  Within  the  canalis  spiralis 
modioli,  which  tunnels  around  the  modiolus  near  the  junction 
of  the  bony  lamina  spiralis,  rest  the  enlarged  terminations, 
ganglia  spirala,  of  the  cochlear  branch,  from  which  filaments 

Fig.  42. 


Section  of  the  osseous  capsule  and  of  the  modiolus  of  the  cochlea  with  the  lamina 
spiralis  ossea  :  a,  internal  auditory  meatus ;  b,  modiolus.    (Politzer.) 


pass  through  minute  canals  in  the  spiral  lamina  to  the  organ 
of  Corti,  which  is  situated  upon  the  membranous  lamina 
spiralis. 

The  Membranous  Labyrinth. 

As  indicated  previously,  the  membranous  labyrinth  con- 
sists of  a  series  of  fibrous  pouches  and  tubes,  filled  with  an 
endolymph,  which  form  a  loosely  attached  inner  lining  of  the 
bony  labyrinth,  from  the  walls  of  which  it  is  separated  by  an 
intervening  perilymph.  Hence,  the  outlines  of  the  mem- 
branous labyrinth  resemble  those  of  the  osseous  portion 
(Fig.  43). 

The  Utricle. — This  oblong  sac  forms  the  greater  part  of  the 


THE  PERCEPTIVE  MECHANISM, 


159 


vestibular  portion  of  the  labyrinth,  and  occupies  the  posterior 
part  of  the  bony  vestibule,  forming  an  attachment  to  the 
inner  wall  in  the  fovea  hemi-elliptica.  Within  the  utricle 
at  this  point  there  is  a  macula  acustica  with  its  specialized 
protoplasmic  cilia,  which  receive  neural  filaments  from  the 
auditory  nerve.  Posteriorly  the  utricular  cavity  communi- 
cates with  the  membranous  semicircular  canals. 

The  Saccule. — This  globular  pouch  lies  antra-inferiorly  to 
the  utricule  in  the  fovea  hemispherica  near  the  mouth  of  the 


Fig.  43. 


^Ampullce 


Canalis  Reuniens 
The  membranous  labyrinth. 

cochlea.  A  macula  acustica  is  also  present  in  the  saccule  at 
the  point  of  its  attachment  in  the  hemispherical  depression, 
from  the  bottom  of  which  tiny  nerve-filaments  enter  the 
macula.  No  communication  is  demonstrable  between  the 
utricle  and  the  saccular  cavity,  though  the  latter  joins  that 
of  the  scala  media  through  a  minute  passage,  the  canalis 
reuniens. 

The  Membranous  Semicircular  Canals. — In  number  and 
shape  these  correspond  to  the  bony  canals  which  they  line, 
and  become  continuous  with  the  utricular  cavity,  as  indicated 


160 


ANAlVMT  A^D  PHYStOLOQY. 


in  Fig.  43.  In  the  ampullae  there  occur  the  cristae  acusticae, 
vvliich  are  similar  to  the  specialized  areas  of  the  utricle  and 
saccule  and  also  receive  filaments  from  the  auditory  nerve. 

The  Scala  Media  or  Ductus  Cochlearis. — This  triangular 
membranous  passage,  which  traverses  the  entire  length  of  the 
spiral  canal  of  the  cochlea,  is  a  subdivision  of  the  outer  por- 
tion of  the  scala  vestibuli,  formed  by  the  membranous  spiral 

Fig.  44. 


Section  through  the  first  turn  of  the  cochlea  of  a  newborn  infant:  S,c.v,  scala  ves- 
tibuli ;  Sc.i,  scala  tympani ;  k,  lamina  spiralis  ossea ;  ft,  lamina  basilaris ;  I,  liga- 
mentum  spirale ;  JR,  membrana  vestibularis ;  Dc,  ramus  cochlearis  ;  o,  Corti's  organ ; 
m,  Corti's  membrane  ;  n,  fasciculus  of  the  ramus ;  g$,  ganglia  spirale.  From  a  prepa- 
ration in  the  author's  collection.    (Politzer.) 

lamina  or  membrana  basilaris,  ligamentum  spirale,  and  the 
membrane  of  Reissner  (Fig.  44).  Upon  the  basilar  mem- 
brane rests  the  remarkable  perceptive  mechanism  of  Corti. 
In  general  the  organ  of  Corti,  as  it  is  termed,  consists  of  a 
ridge  of  polymorphous  cells  (Fig.  45),  formed  by  two  rows  of 
modified  columnar,  epithelial  cells,  which,  separated  at  the 
base,  incline  toward  each  other  and  interlock  at  the  top, 
forming  an  archway  within  which  a  minute  triangular  pas- 


THE  PERCEPTIVE  MECBANISM. 


IGl 


Sage,  tunnel  of  Corti,  is  enclosed.  Upon  either  side  of 
tliis  epithelial  arch  rests  a  group  of  specialized  neuro-epi- 
thelium,  from  the  top  of  Avhich  minute  cilia  project  into  the 
lumen  of  the  canal,  which  is  filled  with  a  thin  fluid.  Be- 
yond this  group  the  modified  cells  gradually  merge  into  the 
epithelial  layer  of  the  membrana  basilaris.  From  the  gan- 
glia spirala,  tiny  neural  filaments  may  be  traced  to  the  ciliated 
epithelia  through  minute  passages  in  the  osseous  spiral  lamina. 
Extending  from  an  epithelial  thickening  upon  the  upper  edge 
of  the  bony  lamina  spiralis,  a  membrana  Corti  projects  to  the 

Fig.  45. 


Terminal  filaments  of  the  cochlear  nerve,  with  Corti's  orfjan,  as  found  in  the 
human  subject:  o,  lamina  spiralis  ossea,  with  the  nerve-bundle  of  the  ramus  coch- 
learis ;  pi,  lamina  spiralis  membranacea;   H,  tooth  of  Huschke    (crista  spiralis); 

C,  inner  rods  of  Corti :  C",  outer  rods  of  Corti ;  r,  lamina  reticularis  :  Z.  Corti's  cells  ; 

D,  Deiter's  cells;  //),  inner  hair-cells ;  oh,  four  outer  hair-cells;  e,  radiating  tunnel 
fibres  of  the  ramus  cochlearis  passing  to  the  cells  of  Corti ;  k,  cells  of  the  sulcus 
spiralis  interior;  CI,  Hensen's  supporting  cells;  cm,  Corti's  membrane;  vs,  vas 
spirale ;  tr,  ligamentum  spirale.    (Politzer.) 


ligamenfcum  spirale  of  the  outer  wall,  thus  separating  the 
organ  of  Corti  from  the  rest  of  the  scala  media. 

The  Arteries  of  the  Lab3rrinth. — The  vestibular  and  cochlear 
branches  of  the  internal  auditory  artery  form  the  chief  blood- 
supply  of  the  internal  ear,  through  anastomosis  with  the 
tympanic  plexus  through  the  internal  wall  of  the  tympanum, 
as  previously  quoted  from  Politzer. 

The  Auditory  Nerve. — After  a  division  in  the  internal 
auditory  meatus  the  auditory  nerve  is  distributed  to  the  laby- 
rinth through  its  two  branches  :  the  vestibular  nerve,  which 
through  its  three  subdivisions  sends  filaments  to  the  maculae 

11— E.  E. 


162  EXAMINATION  OF  THE  PATIENT. 

of  the  utricle,  saccule,  and  semicircular  canals;  while  the 
cochlear  nerve,  which  traverses  the  modiolus,  ends  with  the 
ganglia  spiralis,  from  which  a  large  number  of  minute  fila- 
ments terminate  in  the  ciliated  cells  of  the  organ  of  Corti. 

Thus  the  sonorous  vibrations  imparted  to  the  membrana 
tympani  from  without  are  transmitted  across  the  tympanic 
cavity  by  the  ossicular  chain,  which,  impinging  upon  the 
fluid  contents  of  the  labyrinth,  sets  in  harmonious  motion  the 
cilia  of  the  organ  of  Corti,  from  which  the  impulse  through 
the  intervening  auditory  nerve  reaches  the  auditory  centre  of 
the  brain  and  is  there  interpreted  as  sound. 

QUESTIONS. 

Give  the  classification  of  the  organ  of  hearing. 

What  is  the  general  direction  of  the  auditory  canal  ? 

Describe  the  anatomy  of  the  tympanic  cavity. 

What  important  structures  are  associated  with  the  mastoid  ? 

What  is  the  function  of  the  Eustachian  tube? 

Name  the  subdivisions  of  the  internal  ear. 

Describe  the  scala  media  and  the  organ  of  Corti. 

Give  the  physiology  of  hearing. 


CHAPTER  II. 

EXAMINATION  OF  THE  PATIENT. 

HISTORY   OF   THE   AFFECTION. 

When  a  patient  presents  himself  for  consultation  regard- 
ing an  ear  trouble,  the  problem  which  confronts  the  physician 
is  the  determination  of  the  cause,  location,  and  extent  of  the 
aifection.  The  first  procedure,  then,  should  be  the  elicitation 
of  a  complete  history  as  to  the  probable  etiology,  symptoms, 
and  duration  of  the  disease,  remembering  that  inflammatory 
conditions  of  the  nasopharynx,  resulting  from  either  local  or 
systemic  disorders,  are  the  usual  cause  of  aural  disturbances. 
Specific  information  should  be  obtained  as  to  the  presence  of 
impaired  function,  pain,  tinnitus,  discharge,  and  vertigo. 
From  these  data  alone  a  diagnosis  may  frequently  be  made,  but 


PHYSICAL  EXAMINATION. 


163 


a  thorough  physical  and  functional  examination  by  the  fol- 
lowing methods  will  frequently  reveal  the  presence  of  an 
unsuspected  condition.  Too  much  emphasis  can  not  be  laid 
upon  the  importance  of  details  in  aural  work,  both  in  the 
examination  and  treatment  of  the  conditions  present,  for 
therein  only  lies  the  secret  of  obtaining  successful  results. 

PHYSICAL    EXAMINATION. 

Inspection  of  the  External  Parts. — In  the  examination  of 
the  aural  region  the  physician  should  note  the  condition  of 
the  auricle,  the  orifice  of  the  external  auditory  meatus,  the 
parotid  gland  in  front,  and  the  mastoid  process  behind.     Spe- 


FiG.  46. 


Head  mirror. 

cial  attention  should  be  directed  to  the  latter,  as  it  is 
always  liable  to  be  involved  in  inflammatory  conditions  of  the 
tympanum.  A  comparison  of  the  part  should  be  made  with 
that  of  the  opposite  side,  especially  if  malformations  or  swell- 
iyigs  be  suspected,  or  a  tenderness  of  any  portion  be  elicited  by 
palpation. 

Condition  of  the  Meatus  and  Membrana  Tympani. — To  exam- 


164  EXAMINATION  OF  THE  PATIENT. 

ine  these  structures  properly  requires  a  bright  illumination, 
which  may  be  either  natural  or  artificial,  though  the  latter  is 
to  be  preferred  because  of  its  uniformity  of  light ;  a  reflecting 
mirror  (Fig.  46)  attached  to  a  headband  so  that  the  hands 
may  be  free  to  manipulate  the  auricle  and  the  necessary  instru- 
ments ;  and  a  speculum  (Fig.  47)  to  separate  the  sides  of  the 
cartilaginous  meatus,  thus  permitting  the  light  which  is 
reflected  from  the  mirror  to  be  directed  into  the  canal.  In 
the  introduction  of  the  speculum  the  curved  direction  of  the 
meatus,  as  previously  indicated,  may  be  straightened,  in  the 
adult,  by  drawing  the  auricle  upward,  backward,  and  out- 
ward, while  in  the  child  the  auricle  should  be  pulled  down- 
ward and  backward,  thus  separating  the  upper  and  lower 
walls,  which  are  membranous  and  frequently  lie  in  contact. 

Fig.  47. 


Gruber's  speculum. 

When  instrumental  examination  of  the  canal  is  made  with 
either  the  speculum  or  the  probe,  a  reflex  cough  is  sometimes 
produced,  which  may  be  so  marked  as  to  interfere  seriously 
with  the  proper  inspection  of  the  interior  of  the  meatus.  As 
the  speculum  enters,  the  examiner  should  note  within  the  canal 
the  size  of  the  lumen,  its  shape,  length,  condition  of  the  lining 
epithelium,  amount  of  cerumen,  and  the  number  and  arrange- 
ment of  the  hairs,  as  all  may  be  factors  in  the  production  or 
aggravation  of  a  pathological  condition  within  the  meatus  or 
even  the  tympanum. 

Extending  across  the  distal  end  of  the  canal  will  be  seen 
the  membrana  tympani,  which  presents  normally  a  pearly 
gray  appearance.  From  its  antra-superior  aspect  will  be  ob- 
served the  faint  outlines  of  the  long  liandle  of  the  malleus  as 
it  extends  downward  and  backward  between  the  outer  dermal 


PHYSICAL  EXAMINATION. 


165 


layer  and  the  inner  mucous  cov^ering  of  the  membrane,  ter- 
minating in  a  slight  depression,  umbo,  at  the  centre  (Fig.  48). 
At  the  upper  extremity  of  the  long  handle,  the  short  process, 
resembling  in  appearance  a  small  pustule,  is  distinctly  outlined, 
from  which  point  the  lower  folds  of  the  membrana  flaccida 
may  be  followed  anteriorly  and  posteriorly  to  the  wall  of  the 
meatus.  The  cone  of  light,  which  occupies  the  antra-inferior 
quadrant  of  the  drum  membrane  normally,  may  be  displaced, 

Fig.  48. 


The  normal  membrana  tympani  (right  ear) :  1,  membrana  flaccida ;  2,  long  handle ; 
3,  cone  of  light ;  4,  membrana  vibrans ;  5,  umbo ;  6,  short  handle. 


distorted,  or  even  absent,  due  usually  to  an  inward  bulging, 
retraction  of  the  membrana  tympani,  resulting  from  an  im- 
proper aeration  of  the  tympanic  cavity  through  a  partial  or 
complete  occlusion  of  the  Eustachian  tube ;  though  an  out- 
ward curving  of  the  membrane,  resulting  from  the  pressure  of 
a  fluid  within  the  tympanum,  may  also  cause  the  cone  of 
light  to  disappear. 

The  points  in  an  inspection  of  the  tympanic  membrane  to  be 
specially  observed  are  its  color,  position,  evenness  of  surface, 
and  cootinuity  of  structure.     The  usual  alterations  in  color 


166  EXAMINATION  OF  THE  PATIENT. 

are  produced  by  an  infJammatory  condition  within  the  meatus 
or  tympanum,  when  the  membrane  assumes  a  tint  ranging 
fi'om  a  slight  pinkish  flush  to  that  of  an  angry,  dark,  red- 
dened, injected  condition,  while  formations  of  atrophic  areas, 
cicatrices,  and  calcareous  deposits  produce  whitened  areas  in 
the  membrane.  The  deviations  of  the  normal  position  are 
traceable  to  either  a  tubal  obstruction  or  tympanic  adhesions 
to  the  inner  wall  of  the  tympanum,  when  the  drum  mem- 
brane is  forced  inward,  or  a  fluid,  serous  or  purulent,  within 
the  middle  ear,  when  the  membrane  will  bulge  outward  if  the 

Fig.  49. 


Siegel's  otoscope,  with  rarefler. 

intratympanic  pressure  be  sufficient.  Atrophic  areas,  various 
deposits,  ulcerations,  polypi,  and  granulations,  together  with 
internal  adhesions,  are  the  common  disturbing  elements  of  the 
evenness  of  surface.  An  interruption  in  the  continuity  of 
structure  results  either  from  an  inflammatory  condition,  per- 
foration, or  ulceration,  a  blow  upon  the  auricle  leading  to 
rupture,  or  from  a  surgical  procedure,  incision,  for  therapeutic 
or  exploratory  purposes. 

Atrophic  areas  and  adhesions  of  the  membrana  tympani  to 
intratympanic  structures  are  diagnosed,  in  questionable  in- 
stances, by  the  aid  of  the  Siegel  otoscope  (Fig.  49),  with 
which  the  air  in  the  external  auditory  meatus  may  be  rarefied, 
when  it  will  be  observed,  while  inspecting  the  drum  head 
through  the  instrqnient,  that  with  each  movement  of  the  piston 


PHYSICAL  EXAMINATION.  167 

in  rarefaction  and  condensation  there  will  he  a  corresponding 
outward  and  inward  excursion  of  the  whole  membrane  with 
an  evenness  of  surface ;  but  in  the  atrophic  areas  the  bulg- 
ing will  be  greater  than  that  of  the  rest  of  the  membrane ; 
while  with  internal  adhesions,  areas  will  be  seen  where  the 
mobility  is  restricted  or  lost,  corresponding  to  the  point  of 
attachment. 

Examination  of  the  Nasopharynx. — As  previously  noted,  the 
nasal  and  pharyngeal  passages  should  be  carefully  examined 
in  all  aural  disturbances  where  an  inflammatory  condition 
may  exist,  as  an  involvement  of  the  tympanum  frequently 
results  from  extension  of  an  inflammatory  process  through 
the  Eustachian  tube.  The  respiration  should  be  free  through 
the  nares,  which  often  are  narrowed  by  an  hypertrophic  con- 
dition of  the  turbinal  mucous  membrane,  though  the  turbinate 
bone  itself  may  be  enlarged  congenitally  or  through  disease. 
Malformations  of  the  septum,  comprising  deviations,  spurs, 
thickenings,  will  also  frequently  sufficiently  impede  the  influx 
of  air  to  account  for  a  chronic  congestion,  if  not  inflammation, 
of  the  mucous  membrane  in  and  about  the  pharyngeal  orifice 
of  the  Eustachian  tube.  In  an  examination  of  the  pharynx 
the  usual  etiological  factors  observed  are  an  hypertrophic, 
granular  or  follicular  pharyngitis,  enlargement  of  the  faucial 
tonsils,  or  adenoids  in  the  pharyngeal  vault.  For  details  in 
the  examination  and  treatment  of  these  conditions,  consult  the 
volume  on  Diseases  of  the  Nose  and  Throat  of  this  series. 

Examination  of  the  Eustachian  Tube. — While  making  the 
physical  examination  of  the  nasopharynx,  the  condition  of 
the  Eustachian  orifice  should  be  noted  and  the  surrounding 
structures  scrutinized  for  the  presence  of  polypi,  enlarged 
lymphatics,  posterior  septal  and  turbinal  deviations,  together 
with  thick,  tenacious  discharges,  any  one  or  all  of  which  are 
capable,  as  are  also  hypertrophic  faucial  tonsils,  of  mechan- 
ically obstructing  the  lumen  of  the  pharyngeal  meatus. 

To  determine  the  patency  of  the  Eustachian  tube  the  follow- 
ing methods  are  in  vogue,  by  means  of  which  air  may  be 
forced  through  the  tube  into  the  tympanic  cavity,  when,  if 
the  passage  be  partially  or  completely  occluded,  the  functiou 


168  EXAMINATION  OF  THE  PATIENT. 

of  audition  will  be  correspondingly  improved  thereby,  pro- 
viding there  be  no  organic  lesions  of  the  conducting  or 
perceptive  mechanisms.  While  employing  any  of  these 
procedures,  the  physician  should  use  the  auscultation  tube 
(Fig.  50),  one  end  being  placed  in  the  examiner's  external 
auditory  meatus,  while  the  other  rests  in  the  patient's  meatus, 
by  means  of  which  additional  information  is  gained  as  to  the 
size  of  the  lumen,  presence  of  fluid,  and  the  amount  of  press- 
ure necessary  to  drive  the  air  through  the  canal.  By  this 
method  alone  is  the  operator  often  certain  that  the  entering 
air  has  reached  the  tympanum,  when  the  impact  of  the  air- 
current  will  be  heard  against  the  membrana  tympani,  and 

Fig.  50. 


Auscultation  tube. 


the  resulting  outward  movement  of  the  patient's  drum  head 
will  produce  an  inward  excursion  of  that  of  the  examiner's, 
which  he  can  easily  feel. 

The  Valsalva  Method. — This  procedure  consists  of  an  attempt 
at  forced  expiration  while  the  nose  and  mouth  are  held  firmly 
closed,  thus  forcing  the  air  through  the  passage  of  least  resist- 
ance, the  Eustachian  tube.  This  method  should  be  used  only 
in  determining  the  permeability  of  the  tube  or  the  mobility 
of  the  membrana  tympani  and  ossicles,  and  should  not  be  taught 
the  patient  to  be  used  at  will  as  a  therapeutic  means  of  re- 
lieving the  stenosis  of  the  canal,  as  the  resulting  congestion 
incident  to  its  employment  tends  to  aggravate  an  existing  in- 
jection of  th^  twb?il  ^nd  tympanic  mucoiis  membraqc,     A 


PHYSICAL  EXAMINATION. 


169 


relaxed  condition  of  the  membrana  tympani  or  ossicles  also 
not  infrequently  follows  its  repeated  and  forcible  use. 

The  Politzer  Method. — In  using  this  mode  of  inflation  the 
patient  is  directed  to  take  a  sip  of  water  from  a  glass  and 
retain  it  within  the  mouth  until  instructed  by  the  physician 
by  word  or  sign  to  swallow.  The  nozzle  of  a  Politzer  air- 
bag  (Fig.  51)  is  placed  snugly  into  one  nostril,  while  the  other 
is  held  firmly  closed.  The  patient  then  swallows  at  the  given 
signal,  and  the  air-bag  is  simultaneously  compressed,  when. 


Fig.  51. 


Politzer  bag,  with  glass  inhaler  attached. 

if  the  soft  palate  rests  tightly  enough  against  the  pharyngeal 
wall,  the  air  makes  its  passage  up  the  Eustachian  tube  into 
the  tympanum,  as  may  be  heard  by  the  auscultation  test. 
Instead  of  employing  the  act  of  swallowing  to  close  the 
pharyngeal  space,  the  patient  may  be  instructed  to  forcibly 
pronounce  the  word  "  hook,''  prolonging  the  "  k  "  sound,  or 
markedly  distend  the  cheeks  in  an  attempt  at  forced  expira- 
tion, when  the  air-bag  may  be  used  as  previously  indicated.  The 
compression  of  the  air-bag  should  always  be  guarded  until  the 
accessary  forc^  of  inflation  is  learned^  otherwise^  if  the  tube 


170  EXAMINATION  OF  THE  PATIENT. 

be  patent  and  a  strong  compression  made,  tlie  forcible  entrance 
of  the  air  into  the  tympanic  cavity  will  be  attended  with 
great  discomfort,  if  not  actual  pain,  and  frequently  vertigo  is 
thus  momentarily  produced  by  the  sudden  outward  move- 
ment of  the  foot-plate  of  the  stapes,  which  lowers  the  intra- 
labyrinthine  pressure.  Rupture  of  the  membrana  tympani 
has  resulted  from  the  presence  of  these  conditions,  attended 
with  atrophic  areas  in  the  drum  membrane,  which  are,  of 
course,  points  of  weakened  resistance. 

The  Principles  of  Catheterization  of  the  Eustachian  Tube. — 
Before  attempting  to  employ  the  catheter,  the  operator  should 
examine  the  nasal  cavity  for  any  obstructions  that  may  inter- 
fere with  the  passage  of  the  catheter ;  and  to  render  the  pro- 
cedure less  objectionable  to  the  patient,  a  4  per  cent,  solution 
of  cocaine  may  be  sprayed  into  the  nostrils  or  preferably  applied 
directly  by  means  of  a  cotton-tipped  applicator  unless  the  patient 

Fig.  52. 


Blake's  Eustachian  catheter. 

has  an  idiosyncrasy  against  the  drug.  Whether  a  metallic  or 
hard-rubber  catheter  should  be  employed  is  a  matter  of  per- 
sonal choice  and  experience.  For  his  own  use  the  writer 
prefers  the  silver  probe-pointed  instrument  as  devised  by 
Blake  (Fig.  52),  w^hich  permits  of  changes  being  made  in  its 
curvature  by  bending  and  its  sterilization  by  means  of  steam. 
These  catheters  come  in  four  different  sizes,  to  fit  the  various- 
sized  orifices  of  the  Eustachian  tube,  but  No.  2  is  the  size  most 
frequently  employed. 

For  the  inflation  of  the  tube  after  the  catheter  has  been 
placed  in  the  Eustachian  orifice,  an  ordinary  atomizer-bulb 
should  be  attached  to  the  funnel-shaped  end  of  the  catheter, 
before  its  introduction,  by  means  of  a  small  flexible  inter- 
vening rubber  tube  about  one  foot  in  length.  Otherwise,  if 
the  bulb  were  connected  after  the  passage  of  the  catheter, 
the  necessary  manipulations  would  be  liable  to  displace  th^ 
patheter  an4  discomfort  the  patient  verv  much, 


PHYSICAL  EXAMINATION. 


171 


The  Technique  of  Catheterization  of  the  Eustachian  Tube. — 
Seated  or  standing  in  front  of  the  patient,  the  examiner  places 
the  fingers  of  the  left  liand  upon  the  patientAs  forehead,  while 
with  the  thumb  the  end  of  the  nose  is  forced  upward.  With 
the  other  hand,  while  the  patient  is  holding  the  bulb,  the 


Fig.  53. 


Vertical  section  of  the  nasopharynx,  with  the  catheter  introduced  into  the 
Eustachian  lube  :  A,  inferior  turbinated  bone :  B,  middle  turbinated  bone  ;  C,  supe- 
rior turbinated  bone ;  D,  hard  palate ;  E,  velum  palati ;  F,  posterior  pharyngeal 
wall ;  G,  Rosenmiiller's  fossa ;  H,  posterior  lip  of  the  orifice  of  the  Eustachian  tube. 
(Politzer.) 


operator  introduces  the  probe-pointed  extremity  into  the 
nostril  with  the  curved  portion  directed  downward  and 
resting  upon  the  floor  of  the  nasal  cavity.  The  catheter 
is  gently  pushed  along  the  inferior  meatus  until  the  curved 
^^tremity  reaches  the  postpharyngeal  w^all,  when  the  cath^ 


172  EXAMINATION  OF  THE  PATIENT. 

eter  may  be  introduced  into  the  Eustachian  orifice  by  one 
of  two  courses :  (1)  It  is  now  rotated  directly  inward  and 
brought  forward  until  the  curved  portion  rests  against  the 
posterior  end  of  the  septum.  The  catheter  is  so  turned  that 
the  probe  end  describes  a  semicircle,  passing  downward  along 
the  posterior  surface  of  the  soft  palate  and  finally  coming  to  a 
rest  directly  outward  with  the  ring  of  the  funnel  end  pointing 
toward  the  external  auditory  meatus,  when  the  probe  end 
will  pass,  with  some  manipulation,  into  the  mouth  of  the 
Eustachian  tube.  (2)  After  the  catheter  has  reached  the  pha- 
ryngeal wall  the  instrument  is  withdrawn  slightly  and  rotated 
so  that  the  curved  end  passes  from  below  to  a  position  almost 
directly  outward  toward  the  ear  to  be  inflated.  The  extremity 
in  the  hand  is  then  elevated  and  carried  toward  the  opposite 
side,  when  the  probe  end  will  encounter  the  side  of  the 
pharynx  just  back  of  the  Eustachian  protuberance.  The 
catheter  is  now  withdrawn  carefully,  when  the  probe  end 
will  be  felt  to  impinge  against  the  posterior  lip  of  the  orifice, 
and  then,  with  a  little  added  traction,  pass  over  the  lip  into  the 
funnel-shaped  orifice  of  the  Eustachian  tube  (Fig.  53),  impart- 
ing a  definite  sensation  to  the  experienced  hand.  The  catheter 
is  again  rotated  upward  so  that  the  curved  extremity  points,  as 
indicated  by  the  position  of  the  ring,  toward  the  outer  canthus 
of  the  eye  on  the  corresponding  side  of  the  head,  while  the  fun- 
nel end  of  the  instrument  is  carried  toward  the  opposite  side, 
which  forces  the  inner  extremity  into  the  lumen  of  the  pha- 
ryngeal orifice.  The  connecting  bulb  is  now  compressed  by 
the  right  hand,  while  the  left  retains  the  catheter  in  position. 
With  the  auscultation  tube,  the  examiner  listens  for  any  diag- 
nostic signs  as  the  air  passes  through  the  tube  into  the 
tympanum. 

As  to  which  is  the  preferable  method  of  inflation,  Politzera- 
tion  or  catheterization,  will  depend  wholly  upon  the  condi- 
tion of  the  nasal  cavity  and  the  lumen  of  the  Eustachian 
tube,  together  with  the  experience  of  the  operator  with  either 
mode.  The  advantages  of  the  former  are  :  its  ease  of  appli- 
cation, its  utility  in  obstructed  nasal  passages,  nonliability  of 
injuring  the  tubal  or  nasal  uiucous  jnembmne^  and  its  prefer^- 


TESTS  OF  HE  AMINO,  173 

ble  use  in  children  and  nervous  individuals.  With  catheter- 
ization^  however,  the  following  favorable  points  are  observed  : 
one  ear  only  may  be  inflated  ;  amount  of  force  to  open  the  tube 
can  be  definitely  ascertained ;  the  process  may  be  repeated 
without  annoyanc^e  to  the  patient ;  its  success  depends  wholly 
upon  the  operator;  medicated  vapors  and  applications  may  be 
made  directly  to  the  tubal  mucous  membrane  through  the 
catheter,  while  slender  bougies  or  probes  may  be  introduced 
into  the  Eustachian  canal  thereby,  affording  an  additional 
method  of  diagnosis  and  treatment  of  obstructions  within  the 
tube. 

TESTS  OF  HEARING. 

Having  completed  the  physical  examination  of  the  aural 
structures,  the  physician  should  next  determine  carefully  the 
functional  condition  of  the  organ  of  hearing,  and  record  his 
findings  for  future  reference  in  noting  the  course  of  the  dis- 
ease and  the  results  of  treatment. 

Quantitative  Tests  of  Hearing. — In  determining  how  much 
the  function  of  audition  has  been  impaired,  it  is  only  necessary 
to  ascertain  at  what  distance  a  sound  of  given  intensity  and 
pitch  is  heard  and  compare  it  with  that  of  the  normal  ear. 
While  employing  the  various  procedures,  the  patient's  eyes 
should  be  closed  to  eliminate  the  imagination  of  hearing,  and 
the  organ  not  under  the  test  should  be  stopped  by  the  moist- 
ened finger  of  the  patient  or  with  a  tight  plug  of  cotton,  so 
that  only  one  side  will  perceive  the  sound. 

As  impairment  of  hearing  for  conversation  is  usually  the 
first  symptom  recognized  in  aural  disturbances,  the  examiner 
should  note  to  what  extent  the  hearing  is  affected  in  this 
direction  by  speaking  in  an  ordinary  or  w^iispered  tone  of 
voice.  It  is  well  to  employ  short  and  varied  phrases  instead 
of  sentences,  as  the  patient  will  often  construct  the  latter  by 
catching  a  few  of  the  words  only,  and  it  is  equally  important 
that  the  patient  does  not  see  the  face  of  the  speaker,  as  some 
individuals  become  very  adept  in  reading  the  motion  and 
position  of  the  lips. 

Impairment   of   Hearing  for    Sounds. — A   watch    or  small 


174  EXAMINATION  OF  THE  PATIENT 

clock  may  also  be  employed  as  a  test  by  holding  it  beyond 
the  normal  distance  of  hearing  and  gradually  approaching 
the  ear  until  the  ticking  becomes  audible.  A  stop-watch 
is  preferable,  as  the  test  may  be  interrupted  and  thus  tri(;k 
the  patient.  As  the  pitch  and  loudness  of  the  sound  emitted 
by  different  Avatches  or  the  human  voice  vary  markedly, 
Politzer  devised  an  instrument  (Fig.  54)  termed  an  acoumeter, 
which  practically  produces  an  uniformity  of  quality  and  in- 
tensity, by  which  means  different  observers  may  compare 
results;  but,  unfortunately,  its  intensity  of  click,  which  is 
heard   at   45   feet   by   the    normal    ear,    is   too   marked   for 

Fig.  54. 


Politzer's  acoumeter. 

the  detection  of  slight  alterations  in  function.  In  these  in- 
stances the  watch  or  tuning-fork  offers  a  more  delicate  and 
reliable  method  of  testing.  In  recording  the  findings  of  a 
quantitative  test,  a  note  may  be  made  of  the  distance  at  which 
the  instrument  is  heard ;  but  preferably  the  results  should 
be  designated  by  a  fractional  term,  which  will  indicate  at  a 
glance  the  amount  of  defect  as  compared  with  that  of  the 
normal  ear.  For  instance,  if  the  tick  of  a  given  watch  be 
heard  at  60  inches  normally,  and  the  patient  perceives  the 
sound  at  30  inches,  then  the  fraction  |f  would  indicate  defi- 
nitely the  state  of  his  hearing,  and  would  be  understood  by 
other  observers  in  the  same  line  of  practice. 


TESTS  OF  HEARtm.  175 

Qualitative  Tests  of  Hearing. — In  testing  the  quality  of  per- 
ception the  physician  will  find  that  there  is  a  quite  definite 
range  of  hearing  with  the  normal  ear,  which  may  be  altered 
by  diseased  conditions  of  either  the  conducting  or  the  percep- 
tive apparatus.  There  is  a  point  below  which  the  ear  can  not 
hear  lower  placed  sounds,  while  for  the  high  tones  a  corre- 
sponding limit  is  reached  beyond  which  the  sounds  become 
inaudible.  These  dividing-lines  between  audition  and  deaf- 
ness are  designated  as  the  lower  and  upper  limits  of  hearing 
respectively.  By  ascertaining  their  positions,  which  are  nor- 
mally placed  at  16  and  32,500  tone-vibrations  per  second, 
and  determining  the  duration  of  perception  by  air  and  bone 
conduction,  the  examiner  is  thereby  enabled  to  decide  whether 
the  difficulty  be  located  in  the  conducting  or  the  perceptive 
mechanism,  as  these  points  are  fairly  constant  in  the  normal 

Fig.  55. 


c 


<  o 

MEYROWITZ.  (fl  - 


Blake's  tuning-fork. 

state,  but  are  characteristically  altered  in  disorders  of  the 
middle  or  internal  ear. 

For  instance,  if  a  Blake  tuning-fork  (Fig.  55)  making  512 
single  vibrations  per  second  were  held  before  the  external 
auditory  meatus,  it  would  be  heard  normally  for  30  seconds 
or  more,  providing  a  corner  of  the  fork  were  not  directed 
toward  the  canal,  when  the  vibrations  would  be  inaudible ; 
but  with  the  handle  of  the  fork  placed  firmly  against  the 
mastoid  bone,  about  one  inch  directly  back  of  the  external 
auditory  meatus,  the  duration  of  perception  would  approxi- 
mate is  seconds.  Thus  the  duration  of  air  conduction 
is  normally  about  twice  that  of  bone  transmission.  This  pro- 
cedure has  been  named  the  Rinne  test,  in  honor  of  the  scien- 
tist who  first  observed  the  above  relationship  of  air  and 
bone  conduction.  When  the  vibrating-fork  is  held  before  the 
meatus,  the  vibrations  are  imparted  through  the  intervening 


176 


EXAMiNATiON  OF  THE  PATIENT. 


air  to  the  membrana  tympani,  and  thence  to  the  labyrinth 
through  the  ossicular  chain.  Hence,  if  there  be  any  obstruc- 
tion to  its  freedom  of  passage — e.  g.,  a  foreign  substance 
occluding  the  external  auditory  meatus,  or  a  restriction  of 
the  mobility  of  the  drum  head  or  the  ossicles  by  the  presence 
of  adhesions  or  a  fluid  within  the  tympanum — the  duration 
of  hearing  by  air  conduction  will  be  correspondingly  dimin- 
ished. With  the  liandle  directed  against  the  mastoid  bone, 
the  sound-vibrations  of  the  instrument  reach  the  perceptive 
organ  through  the  substance  of  the  bone,  thus  eliminating  the 
conducting  apparatus ;  and  if  the  nervous  mechanism  of  the 
labyrinth,  the  auditory  centre  of  the  brain,  or  the  connect- 
ing auditory  nerve  be  affected,  the  duration  of  bone  conduc- 
tion will  be  limited,  the  amount  depending  upon  the  extent 
of  the  lesion.  Occasionally  in  hypersesthetic  conditions  of  the 
nervous  system  the  duration  and  range  of  audition  appears 
greater  than  normally  observed.  Theoretically  the  duration 
of  air  and  bone  conduction  for  all  musical  sounds  present 
between  the  lower  and  upper  limits  of  hearing  should  be 
ascertained  in  a  complete  test ;  but,  practically,  tuning-forks 
tuned  to  C,  making  128,  256,  512,  1024,  and  2048  single 
vibrations  per  second  respectively,  furnish  a  very  complete 
diagnosis.  The  lower  limit  is  tested  by  means  of  a  large 
tuning-fork    (Fig.   56),    which    records   26    to    64  v.  s.  per 

Fig.  56. 


Denche's  large  tuning-fork. 


second,  while  the  upper  limit  is  determined  with  sufficient 
accuracy  by  the  use  of  the  Galton  whistle  (Fig.  57),  wliich  is 
capable  of  giving  from  3500  to  theoretically  84,000  v.  s.  per 
second,  though  the  Konig  rods  give  the  more  complete  test^ 


TESTS  OF  HEAHtm.  177 

but  require  too  much  time  for  routine  use.  Another  phe- 
nomenon of  aural  perception  has  been  designated  as  the 
Weber  test,  which  is  observed  with  the  handle  of  a  vibrating 
fork  resting  upon  the  skull  in  the  median  line,  either  upon 
tlie  vertex,  forehead,  or  the  maxillary  region,  when,  if  the 
external  auditory  meatus  be  closed  by  the  finger,  the  sound 
will  be  heaj'd  more  distinctly  upon  the  corresponding  side. 
Thus,  clinically,  if  there  be  an  impairment  of  the  hearing  in 

Fig.  57. 


Galton's  whistle. 

one  ear  only,  or  the  two  sides  be  unequally  affected  and  the 
patient  recognizes  the  vibrations  as  louder  in  the  deafened 
ear,  these  facts  indicate  that  an  obstruction  exists  in  the  con- 
ducting apparatus  of  the  same  side,  which  may  be  a  foreign 
body  in  the  meatus,  adhesions  of  the  membrana  tympani  or 
ossicles,  or  fluid  within  the  tympanum  if  the  Eustachian  tube 
be  patent.  Were  the  sound  heard  more  distinctly  upon  the 
better  side,  this  would  point  to  an  impairment  of  the  percep- 
tive mechanism  of  the  more  deafened  ear.  This  method, 
therefore,  should  precede  the  Rinne  test  in  a  systematic  ex- 
amination of  the  hearing. 

In  general,  then,  with  lesions  of  the  conducting  apparatus, 
the  duration  of  air  conduction  is  shortened  (bone  transmission 
remaining  normal),  while  the  lower  tone  limit  is  raised.  In 
affections  of  the  internal  ear,  a  diminution  of  duration  for 
both  air  and  bone  conduction  is  shown,  but  the  latter  is 
relatively  more  reduced,  while  the  upper  limit  is  lowered,  its 
amount  depending  upon  the  extent  of  the  alterations  in  the 
labyrinthine  nervous  mechanism. 

From  the  data  obtained  in  the  physical  and  functional 
examination  of  the  aural  structures,  the  cause,  location,  and 
12— E  E. 


178        DISEASES  OF  THE  AUHICLE  AND  MEATUS. 

extent  of  the  aifection  may  be  determined,  when  the  physician 
will  be  in  position  to  consider  properly  the  methods  of  treat- 
ment. 

QUESTIONS. 

What  points  are  to  be  elicited  in  the  history  of  a  case  ? 
What  structures  are  inspected  in  a  physical  examination  ? 
Describe  the  appearance  of  a  normal  membrana  tympani. 
What  points  should  be  observed  in  its  inspection  ?  «, 

Describe  the  Politzer  method  of  inflation. 
Give  the  technique  and  advantages  of  catheterization. 
Name  the  different  methods  of  testing  the  hearing. 
What  is  meant  by  the  lower  and  upper  limits  of  hearing? 
What  is  Einne's  test  ?    What  is  Weber's  test? 
What  is  the  utility  of  the  qualitative  tests? 
What  instruments  are  necessary  to  make  these  tests  ? 

What  are  the  characteristic  alterations  indicative  of  involvement  of  the 
middle  ear  ?    Of  the  labyrinth  ? 


CHAPTER   III. 


DISEASES  OF  THE  AURICLE  AND  EXTERNAL  AUDITORY 

MEATUS. 

MALFORMATIONS. 

Signifioance. — Occasionally  among  those  who  present  them- 
selves for  consultation  regarding  aural  troubles,  the  physician 
will  note  instances  of  congenital  defects  in  the  auricle  or  the 
external  auditory  meatus,  which  may  exist  without  the  knowl- 
edge of  the  patient,  especially  when  the  malformation  is  not 
marked.  These  freaks  of  Nature  are  sometimes  associated 
with  perversions  of  mind  and  nervous  system,  and  are  thus 
looked  upon  by  many  observers  as  stigmata  of  degeneration. 
While  it  is  true  that  many  cases  occur  apparently  substan- 
tiating this  belief,  the  most  aggravated  forms  of  malformation 
may  exist  without  any  signs  of  impaired  mentality. 

Common  Abnormalities  of  the  Auricle. — Among  the  usual 
deviations  from  normality  may  be  mentioned  the  excessively 
large  or  small  auricle,  abnormality  of  position  or  attachment, 
supernumerary  ridges  or  fossae,  deformities  or  absence  of  the 


SEBACEOUS  CYSTS  179 

tragus,  rudimentary  or  cleft  lobule,  indentations  of  the  helix, 
and  mixed  conditions. 

Common  malformations  of  the  meatus  frequently  appear  with 
those  of  the  auricle,  especially  when  the  latter  involve  the 
structures  about  the  orifice  of  the  canal.  Exostoses  in  the 
bony  portion,  cartilaginous  spurs  in  the  outer  meatal  passage, 
very  small  lumen  (atresia) — which  may  be  round,  but  is 
usually  slit-shaped — or  even  complete  stoppage  or  absence  of 
the  canal  are  conditions  that  may  be  occasionally  met.  Of 
course,  when  the  malformations  markedly  diminish  the  lumen 
of  the  meatus,  deafness  of  various  degrees  will  add  to  the  dis- 
comfort of  the  individual. 

Treatment. — Regarding  the  advisability  of  surgical  pro- 
cedures for  cosmetic  effects,  it  may  be  said  that  much  may  be 
accomplished  for  the  amelioration  of  the  deformity  by  skilfully 
executed  plastic  operations  which  have  for  their  purpose  the 
removal  of  superfluous  structures.  As  to  the  conditions  of 
atresia  and  absence  of  the  meatus,  it  is  a  generally  accepted 
fact  that  surgical  interference  is  often  disappointing  on  account 
of  the  formation  of  cicatrices  and  granulation  tissue,  which 
tend  to  undo  an  otherwise  brilliant  result.  These  cases,  there- 
fore, should  be  referred  to  the  specialist  for  treatment. 

SEBACEOUS   CYSTS. 

Synonyms. — Steroma ;  Wen  ;  Atheroma. 

Definition. — A  sebaceous  cyst  is  a  noninflammatory,  rounded 
— either  soft  or  hard — elastic  tumor,  varying  in  size,  which  is 
produced  by  the  distention  of  a  sebaceous  gland  by  its  retained 
secretions. 

Etiology. — Irritation  of  the  mouth  or  duct  of  the  gland 
from  mechanical  or  inflammatory  sources,  thickened  secretions 
which  can  not  be  discharged  from  the  gland,  and  hyperse- 
cretion. 

Symptoms. — The  tumor  is  usually  located  in  the  lobule, 
though  it  may  occur  at  any  point  upon  the  surface  of  the 
auricle.  In  the  external  auditory  meatus  the  cysts  develop 
in  the  cartilaginous  portion,  where  the  glandular  structures 


180       DISEASES  OF  THE  AUmCLE  AND  MEATUS. 

are  usually  confined.  The  tumor  gradually  enlarges  without 
pain  or  discomfort  unless  appearing  in  the  bony  portion  of  the 
canal,  which  is  rare.  Attaining  a  certain  size,  it  frequently 
remains  stationary  in  its  growth  for  an  indefinite  period 
unless  irritated,  when  the  secretion  is  liable  to  be  increased . 
The  only  interference  with  the  function  of  the  ear  occurs 
when  the  tumor  attains  such  a  size  in  the  meatus  as  nearly  or 
completely  to  occlude  the  lumen,  producing  varying  degrees 
of  deafness,  which  occasionally  is  altered  by  movement  of  the 
jaws,  when  the  lumen  of  the  meatus  is  changed. 

Treatment. — After  producing  anaesthesia  of  the  part  by 
means  of  Schleick^s  injections  or  any  other  local  anaesthetic, 
the  tumor  is  removed  by  a  careful  dissection  so  that  the  sac 
or  distended  gland  is  not  ruptured,  otherwise  its  complete 
removal  will  be  difficult,  and  unless  this  is  accomplished  the 
cyst  is  liable  to  recur.  A  less  preferable  method  is  the  incision 
of  the  sac,  evacuation  of  the  contents,  and  destruction  of  the 
secreting  walls  by  means  of  caustics. 

HiEMATOMA   AURIS. 

Synonyms. — Atha^matoma  ;  Blood  tumor. 

Definition. — Hsematoma  auris  is  a  bluish-red  swelling  of 
the  auricle,  due  to  an  eifusion  of  blood  between  the  cartilage 
and  the  perichondrium. 

Etiology. — This  disorder  is  frequently  the  result  of  a  blow 
upon  the  auricle  or  pulling  of  the  ear,  which  ruptures  a  blood- 
vessel or  separates  the  cartilage  from  the  perichondrium,  into 
which  space  the  blood  flows.  Spontaneous  rupture  of  athe- 
romatous arteries,  formation  of  fissures  or  cavities  in  the  carti- 
lages, proliferation  of  bloodvessels,  and  new  growths  are  also 
recognized  as  etiological  factors. 

Symptoms. — Following  a  traumatism  of  the  auricle,  or 
occurring  spontaneously,  a  tumefaction  suddenly  makes  its 
appearance  upon  either  side  of  the  auricle,  although  it  usually 
occurs  upon  the  anterior  surface,  attended  by  a  painful  sensa- 
tion at  the  site  of  the  swelling  and  a  feeling  of  warmth.  The 
pain  is  sharp  and  stabbing  in  character,  due  to  the  forcible 


PERICHONDRITIS  AURICULJE.  181 

separation  of  the  tissues  by  the  sanguineous  effusion.  On 
account  of  its  frequent  occurrence  among  the  insane,  it  is 
claimed  by  some  authorities  that  instances  of  spontaneity  are 
traceable  to  local  trophic  changes,  resulting  from  intercranial 
lesions.  Others  attribute  its  appearance  in  the  demented  to 
ill  treatment  or  injury  of  the  part  by  the  attendants.  The 
(contents  of  the  swelling  frequently  disappear  by  absorption, 
but  may  become  purulent  in  character,  attended  with  inflam- 
matory symptoms.  Should  the  swelling  extend  to  or  involve 
the  meatus  sufficiently,  the  hearing  will  be  lowered  from  the 
occlusion  of  the  canal,  although  this  is  unusual. 

Treatment. — In  order  to  reduce  the  swelling,  cold  soothing 
compresses  may  be  applied  for  a  time,  wdien,  if  the  tumefac- 
tion does  not  abate,  an  incision  should  be  made  at  the  most 
prominent  point  and  the  contents  evacuated,  following  strict 
antiseptic  procedures  in  the  after-treatment.  If  the  tumor  be 
small,  resolution  may  occur  without  interference.  The  patient 
should  be  warned  that  deformity  of  the  auricle  is  liable  to 
result  from  the  cicatricial  contractions  consequent  upon  this 
affection,  especially  if  the  effusion  of  blood  has  been  extensive. 

PERICHONDRITIS  AURICULAE. 

Definition. — An  acute  inflammation  of  the  perichondrium. 

Etiology. — May  follow  hsematoma  auris  as  a  complication  ; 
often  results  from  traumatism  or  frost-bites  of  the  auricle. 

Symptoms. — With  the  gradual  appearance  of  an  inflamma- 
tion of  the  auricle,  a  bright-red  swelling,  which  may  occur  at 
any  point,  slowly  makes  its  appearance,  attended  with  severe 
pain  and  a  feeling  of  heat  in  the  affected  area.  The  serous 
effusion  between  the  cartilage  and  the  perichondrium,  which 
accounts  for  the  enlargement,  may  become  so  extensive  as  to 
involve  the  entire  auricle,  obliterating  the  ridges  and  fossae  as 
the  perichondrium  is  dissected  from  the  cartilaginous  frame- 
w^ork.  Later  the  serous  contents  of  the  tumor  may  become 
purulent  in  character,  which  adds  to  the  gravity  of  the  condi- 
tion. If  left  to  itself,  spontaneous  evacuation  of  the  fluid  will 
result  from  perforation,  followed  with  great  deformity.     The 


182        DISEASES  OF  THE  AURICLE  AND  MEATUS. 

diiferential  diagnosis  of  perichondritis  from  hsematoma  rests 
upon  the  fact  that  in  the  latter  the  swelling  which  results 
from  an  effusion  of  blood  appears  suddenly  and  unattended 
with  inflammatory  conditions,  while  the  perichondritic  exu- 
date is  serous  and  produces  its  enlargement  gradually,  follow- 
ing a  previous  inflammatory  state. 

Treatment. — Practically  that  of  hsematoma  auris. 

ECZEMA. 

Synonyms. — Salt  rheum  ;  Moist  tetter ;  Milk  crust ;  Scalds 

Definition. — -Eczema  is  an  acute  or  chronic,  multiform,  in- 
flammatory disease  of  the  skin,  characterized  by  the  forma- 
tion of  vesicles,  papules,  or  pustules  attended  with  infiltration 
and  thickening  of  the  epidermis,  and  terminating  in  a  desqua- 
mation or  a  seropurulent  discharge  with  the  formation  of 
crusts. 

Etiology. — The  causes  of  this  dermatitis  are :  (1)  predispos- 
ing constitutional  disorders,  among  which  may  be  mentioned 
rheumatic  tendencies,  dyspepsia,  constipation,  mental  and 
physical  exhaustion,  and  the  neuroses  of  functional  or  organic 
origin ;  and  (2)  local  causes  producing  irritation  of  the  skin, 
such  as  excessive  heat  or  cold,  strong  soaps,  acids,  alkalies, 
injuries  of  the  skin,  which  in  the  case  of  involvement  of  the 
external  auditory  canal  frequently  results  from  foreign  bodies 
being  introduced  into  the  meatus  with  the  intention  of  scratch- 
ing the  skin  or  removing  the  ear  wax,  inspissated  or  impacted 
cerumen,  and  irritation  by  a  chronic  discharge  from  the  tym- 
panum. 

Symptoms. — The  most  pronounced  symptom  is  the  itching, 
pricking,  or  burning  sensation  which  first  calls  attention  to 
the  part,  congestion  of  the  region  affected,  presence  of  an 
exudate,  formation  of  crusts,  thickening  of  the  skin,  develop- 
ment of  fissures,  and  desquamation.  If  the  meatus  be  aifected, 
the  hearing  may  be  altered  mechanically  by  the  presence  of 
crusts,  discharges,  desquamations,  or  swelling  of  the  skin, 
which  might  obstruct  the  lumen  of  the  canal  sufficiently. 

Treatment. — In  general  remove  the  local  and  predisposing 


DIFFUSE  EXTERNAL   OTITIS.  183 

systemic  causes,  advise  hygienic  and  dietetic  measures,  apply 
locally  soothing  and  protective  medication  in  the  acute  form, 
and  stimulating  ointments  in  the  chronic  state.  Removal  of 
the  crusts  is  best  accomplished  by  an  oily  preparation.  For 
details  of  treatment  consult  a  work  on  diseases  of  the  skin,  as 
eczema  in  this  region  does  not  differ  from  that  affecting  any 
other  part  of  the  body.  Care  should  be  exercised  that  the 
membrana  tympani  be  not  injured  by  either  the  medication 
employed  or  the  instruments  used  in  its  application. 

DIFFUSE  EXTERNAL  OTITIS. 

Occurrence. — This  form  of  inflammation  of  the  external 
auditory  meatus  may  occur  either  as  an  acute  or  chronic  affec- 
tion which  involves,  as  its  name  implies,  the  greater  portion, 
if  not  the  whole,  of  the  meatal  lining  membrane,  gradually 
merging  into  the  surrounding  epithelium. 

Synonyms. — Otitis  externa  diffusa  acuta ;  Diffuse  inflamma- 
tion of  the  external  ear. 

Etiology. — As  an  idiopathic  affection,  the  disease  is  rare. 
Usually  it  results  from  pathogenic  microbic  infection  which 
enters  through  abrasions  of  the  skin  produced  by  traumatic 
influences,  foreign  bodies  introduced  into  the  canal,  irritation 
by  discharges  from  the  tympanic  cavity,  or  the  instillation 
of  improper  fluids  into  the  meatus,  and  secondary  to  furun- 
cular  inflammations  of  the  epithelium. 

Symptoms. — The  symptoms  are  especially  marked  when  the 
disease  involves  the  osseous  portion  of  the  canal  and  the  sur- 
face of  the  membrana  tympani.  Beginning  with  an  itching 
sensation,  a  violent,  radiating  pain  soon  follows,  which  is  in- 
creased by  movements  of  the  jaws,  manipulation  of  the  auri- 
cle, and  lying  upon  the  affected  side.  Tinnitus  and  deafness 
may  supervene.  The  inflammation  first  makes  its  appearance 
as  a  congestion  of  the  cutis,  followed  by  marked  s-welling  and 
infiltration  ;  development  of  a  serous  or  purulent  discharge 
which  softens  the  cuticle ;  exfoliation  of  the  whitened,  mace- 
rated dermal  layers,  leaving  an  angry,  excoriated  surface 
which  is  extremely  sensitive ;  ulcerations  of  the  membrana 


184        DISEASES  OF  THE  AURICLE  AND  MEATUS. 

tympani  may  develop  and  result  in  perforation ;  granulations 
may  spring  from  an  ulcerative  process  of  the  meatal  wall ;  or 
necrosis  of  the  bony  meatus  may  affect  the  unfortunate  indi- 
vidual. In  the  chronic  form  there  may  occur  an  itching  of 
the  skin,  slight  degree  of  pain,  varying  amount  of  discharge, 
and  desquamation  which  may  obstruct  the  canal  by  the  ex- 
foliated debris,  attended  with  a  lowering  of  the  aural  func- 
tion.    Keflex  cough  is  also  thereby  occasionally  produced. 

Diagnosis. — Inspection  of  the  meatus  and  membrana  tympani 
reveals  the  swollen,  infiltrated  condition  of  the  skin,  the  dis- 
charge, and  the  whitened,  exfoliating  layers  of  the  epithelium, 
which  microscopically  show  the  presence  of  micrococci  or 
aspergillus  fungus.  This  condition  might  be  confounded  with 
that  resulting  from  a  purulent  discharge  from  the  tympanum, 
but  in  the  latter  instance  inspection  would  reveal  the  presence 
of  a  perforation  of  the  drum  head,  which  would  indicate  the 
nature  of  the  affection. 

Prognosis. — In  the  idiopathic  cases  the  inflammation  sub- 
sides in  the  course  of  a  few  days,  while  in  those  due  to  a 
traumatic  origin  the  resolution  is  usually  delayed  because  of 
the  complicating  ulcerations  and  attending  granulations,  which 
are  not  only  slow  in  healing,  but  tend  to  the  formation  of 
strictures  and  atresia  of  the  canal. 

Treatment. — In  the  acute  form,  if  the  inflammation  be  mild, 
antiseptic  and  protective  measures  will  usually  suffice;  while 
if  the  inflammatory  conditions  be  marked,  the  patient  should 
be  put  to  bed,  a  saline  purgative  given,  a  hypodermic  admin- 
istered if  necessary  for  the  relief  of  the  pain,  the  canal 
syringed  with  warm  solutions  of  boric  acid  (saturated), 
bichloride  of  mercury  (1:8,000),  or  carbolic  acid  (1:40), 
artificial  leech  and  cupping  applied  in  front  of  the  tragus 
or  immediately  behind  the  auricle  as  is  indicated,  and  the 
application  of  an  ice-bag  or  coil  to  the  mastoid.  If  the  swell- 
ing does  not  abate  within  a  day  or  so,  scarification  or  incision 
of  the  infiltrated  tissues  extending  down  to  the  bone  will 
prove  beneficial,  especially  in  the  early  stage.  After  the 
canal  has  been  dried  insufflations  of  boric  acid  powder  are 
recommended.     In  the  chronic  form,  after  cleansing  the  canal 


ACUTE  CIRCUMSCRIBED  EXTERNAL   OTITIS.        185 

with  antiseptic  solutions,  applications  of  nitrate  of  silver  solu- 
tion (1  ;  24  or  stronger),  instillation  of  boric-alcohol  (1  :  20), 
or  diachylon  ointment  may  be  used.  If  the  alcoholic  solu- 
tion does  not  remove  the  granulations,  they  may  be  de- 
stroy e<l  by  cauterization,  either  with  solid  nitrate  of  silver, 
chromic  acid,  or  preferably  the  electrocautery,  the  parts  having 
been  previously  anaesthetized  by  the  use  of  powdered  cocaine. 

ACUTE   CIRCUMSCRIBED   EXTERNAL   OTITIS. 

Synonyms. — Otitis  externa  circumscripta  acuta;  Furuncle 
of  the  external  auditory  meatus. 

Etiology. — It  will  be  recalled  that  the  cartilaginous  portion 
of  the  canal  contains  sebaceous  and  ceruminal  glands,  together 
with  hair-follicles,  which  are  liable  to  infection,  thus  pro- 
ducing the  furuncle  or  boil  within  the  meatus.  The  patho- 
logical micro-organisms  gain  entrance  through  abrasions  or 
irritation  of  the  skin  produced  by  various  agencies.  Irrita- 
tion from  foreign  bodies,  instillations  of  caustic  substances, 
chronic  eczema,  diffuse  external  otitis,  and  predisposing  sys- 
temic disorders,  such  as  debility,  dyspepsia,  anaemia,  and  dia- 
betes, are  also  mentioned  as  rendering  the  patient  susceptible 
to  the  affection.  Frequently  idiopathic  instances  occur  in  the 
most  robust  constitutions.  Climatic  conditions  seem  to  exert 
an  etiological  influence  in  the  production  of  this  disease,  as  it 
occurs  more  frequently  during  the  spring  and  autumn  months. 
It  is  more  commonly  observed  in  adults  than  in  children. 

Symptoms. — The  first  symptoms  that  the  patient  may  notice 
will  usually  appear  as  an  itching  or  fulness  in  the  meatus, 
which  gradually  increases,  attended  with  the  development  of 
a  severe,  radiating  pain,  which  is  increased  by  movement  of 
the  jaws,  so  that  mastication  may  become  impossible  ;  pressure 
upon  the  auricle  also  accentuates  the  trouble.  The  pain  may  be 
so  severe  as  to  prevent  sleeping ;  the  appetite  may  be  deranged ; 
debility  and  headache,  together  with  an  elevation  of  tempera- 
ture, may  be  recorded.  If  the  tumefaction  produces  a  stenosis 
of  the  canal,  tinnitus  and  deafness  may  ensue  from  the  me- 
chanical obstruction  of  the  passage  or  the  induced  congestion 


186        DISEASES  OF  THE  AURICLE  AND  MEATUS. 

of  the  tympanum  and  labyrinth.  The  cervical,  parotid,  and 
preauricular  glands  may  become  increased  in  size  from  an 
extending  infiltration  ;  and  occasionally,  if  the  inflammatory 
area  be  situated  upon  the  posterior  wall  of  the  canal,  an  oede- 
matous  condition  may  appear  upon  the  mastoid  immediately 
behind  the  auricle,  which  may  be  diagnosed  a  mastoiditis  by 
the  inexperienced.  Within  the  meatus  it  may  be  observed 
that  the  tumor  or  swelling  appears  flattened,  poorly  defined, 
and  slightly  congested  when  the  abscess  is  located  deep  be- 
neath the  surface;  but  if  developed  superficially,  the  fur- 
uncle usually  presents  a  rounded,  elevated,  reddened  tumor, 
which  nearly  or  completely  obstructs  the  canal,  so  that  it  may 
be  impossible  to  see  the  drum  membrane.  After  four  or  five 
days  the  contents  of  the  tumefaction  become  purulent,  and 
may  rupture  the  surrounding  structures  and  allow  the  dis- 
charge to  escape,  when  the  patient  becomes  more  comfortable 
with  the  resulting  diminution  of  the  swelling  and  pain.  Re- 
lapses are  liable  to  recur  from  stoppage  of  the  perforation 
through  contraction  or  granulation  growths.  Sometimes  sev- 
eral furuncles  succeed  each  other  in  development  or  may 
appear  at  the  same  time.  Occasionally  infection  is  conveyed 
to  the  tympanum,  and  a  resulting  inflammation  of  the  middle 
ear  adds  to  the  discomfort  of  the  unfortunate  sufferer. 

Diagnosis. — As  a  rule  this  is  not  attended  with  any  diffi- 
culty when  the  subjective  symptoms,  together  with  the  signs 
of  inspection,  are  carefully  considered.  Exostoses  of  the 
meatus,  covered  by  an  injected  epithelium  or  bulging  of  the 
posterior  wall  incident  to  inflammation  of  the  mastoid,  might 
be  regarded  as  furuncular  swellings  ;  but  the  judicious  use  of 
the  probe  will  aid  in  the  localization  of  the  trouble. 

Prognosis. — The  termination  of  furunculosis  of  the  meatus 
is  favorable  in  uncomplicated  cases.  Under  proper  treatment 
the  symptoms  disappear  within  the  course  of  a  few  days,  when 
resolution  is  complete. 

Treatment. — As  the  pain  is  the  most  aggravating  symptom 
produced  by  the  infiltration  and  distention  of  the  tissues,  the 
canal  should  be  syringed  with  a  warm  antiseptic  solution,  pref- 
erably carbolic  acid  (1 :  40),  which  will  partially  anaesthetize 


OTOMYCOSIS.  187 

the  skin  and  prevent  reinfection,  followed  by  a  deep  incision 
into  the  most  prominent  portion  of  the  swelling,  whether 
suppuration  be  suspected  or  not.  If  a  purulent  focus  has  not 
formed,  the  escape  of  the  serosanguineous  fluid  relieves  the 
])ain  and  feeling  of  tension  in  the  meatus.  Should  the  knife 
fail  to  reach  the  pus,  it  will  soon  make  its  way  to  the  incision 
through  the  path  of  least  resistance.  Occasionally,  after  spon- 
taneous rupture  has  occurred,  especially  if  the  amount  of  dis- 
charge has  been  small,  it  is  advisable  to  enlarge  the  opening, 
which  may  be  occluded  by  inspissated  suppurative  debris  or 
the  core  of  the  furuncle.  With  the  advent  of  the  purulent 
discharge,  the  canal  should  be  kept  clean  by  means  of  warm 
antiseptic  solutions,  which  will  prevent  infection  of  other  por- 
tions of  the  meatus.  After  drying  the  canal  with  a  pledget 
of  cotton  upon  an  applicator,  a  light  packing  of  antiseptic 
gauze  may  be  introduced  into  the  canal  as  a  means  of  protec- 
tion and  drainage.  This  procedure  should  be  repeated  as 
often  as  occasion  demands.  Applications  of  ichthyol  solu- 
tion (1  : 1),  carbolic-glycerine  (1  :  30),  boric-alcohol  (1  :  20), 
nitrate  of  silver  (1  :  24),  and  hydrogen  peroxide  are  recom- 
mended to  be  employed  in  the  after-treatment ;  but  the  treat- 
ment outlined  above  has  proved  the  most  satisfactory  in  the 
hands  of  the  author. 

Diphtheritic  External  Otitis. — This  rare  condition  of  the 
meatus  usually  occurs  as  a  complication  of  faucial  diphtheria, 
and  its  treatment  is  that  of  the  general  disease,  by  means  of 
antitoxin,  together  with  antiseptic  and  protective  measures 
locally. 

OTOMYCOSIS. 

Occurrence. — Frequently,  among  foreigners  who  live  under 
poor  hygienic  and  dietetic  conditions,  this  parasitic  inflam- 
mation of  the  external  auditory  canal  is  found  to  exist.  It 
is  most  commonly  caused  by  Aspergillus  nigricans  or  Asper- 
gillus flavescens,  which  produces  a  slight  superficial  inflamma- 
tion oif  the  meatal  lining  membrane,  attended  by  symptoms  of 
itching,  pain,  desquamation,  and,  at  times,  tinnitus  and  deaf- 
ness.    The  treatment  consists  of  enforced  hygienic  measures, 


188 


DISEASES  OF  THE  AURICLE  AND  MEATUS, 


removal  of  scaly  debris,  and  application  of  antiseptic  solutions 
or  powders. 

SYPHILIS   OF   THE   MEATUS. 

Usually  being  a  local  manifestation  of  a  general  disorder, 
syphilis  in  this  region  appears  as  condylomata,  ulcerations, 
and  gummata.  The  condition  last  mentioned  is  rarely  con- 
fined to  the  canal,  but  involves  the  tympanic  cavity  and  laby- 
rinth as  well.     Ulcerations  in  the  meatus,  especially  if  deep. 


Aspergillus. 

may  produce  stricture  of  the  passage,  with  resulting  involve- 
ment of  the  hearing. 

The  treatment  consists  of  the  constitutional  administration 
of  mercury  and  potassium  iodide,  and  the  local  use  of  anti- 
septic solutions  employed  as  a  douche,  followed  by  applica- 
tions of  iodoform,  boric  acid,  or  calomel  powders. 


IMPACTED   CERUMEN. 

Significance. — While  this  disorder  does  not  differ  essentially 
in  its  symptomatology  and  treatment  from  that  presented  by 
the  presence  of  other  foreign  bodies  within  the  external  audi- 
tory meatus,  for  the  purpose  of  lucidity  it  seems  advisable  to 


IMPACTED  CERUMEN.  189 

consider  this  affection  under  a  separate  heading,  as  it  obtains 
its  origin  in  a  perversion  of  secretion  and  retention  within  tlie 
canal. 

Synonyms. — Inspissated  cerumen  ;  Ceruminous  phigs. 

Definition. — Impacted  cerumen  is  a  collection  of  an  abnor- 
mal amount  of  ear-wax,  mixed  with  various  kinds  of  debris, 
which  may  partially  or  completely  occlude  the  external  audi- 
tory meatus. 

Etiology. — The  normal  ceruminal  secretion,  which  is  the 
product  of  the  ceruminous  and  sebaceous  glands  which  are 
present  in  the  cartilaginous  portion  of  the  canal,  is  under 
normal  conditions  removed  from  the  meatus  by  the  move- 
ments of  the  inferior  maxillary  and  various  manual  procedures. 
Part  of  the  secretion,  however,  is  occasionally  retained  within 
the  canal  by  various  obstructions,  when  a  nucleus  is  formed 
about  which  the  cerumen  gathers  until  the  passage  is  nearly, 
if  not  entirely,  closed.  Among  the  many  causal  factors  that 
may  be  instrumental  in  the  production  of  ceruminal  plugs 
may  be  mentioned  :  inspissated  secretion  from  the  tympanum  ; 
habitual  or  recurring  hypersemic  conditions  of  the  meatal 
lining  membrane,  which  stimulate  the  glandular  structures 
to  hypersecretion  ;  congenital  or  acquired  strictures  of  the 
meatus,  which  tend  to  retain  the  normal  or  perverted  secre- 
tions within  the  canal ;  a  thickened  condition  of  the  cerumi- 
nous matter;  the  desquamations  of  eczema,  diffuse  external 
otitis,  and  other  scaly  conditions  of  the  meatus ;  and  various 
kinds  of  foreign  bodies  within  the  meatus. 

Symptoms. — It  is  frequently  observed  that  large  collections 
of  cerumen  may  remain  within  the  external  auditory  meatus 
for  many  years  without  any  inconvenience  to  the  patient  so 
long  as  the  plug  does  not  rest  against  the  membrana  tympani 
and  a  passage  is  preserved  between  the  cerumen  and  the 
meatal  wall  for  the  transmission  of  the  sound-waves.  With 
occlusion  of  the  canal  a  sense  of  fulness  is  experienced ;  tin- 
nitus and  deafness  of  varying  degrees  may  ensue ;  itching, 
irritation,  and  even  a  piercing. pain  may  be  produced  by  the 
hardened  mass,  especially  wlien  tlie  jaws  are  moved  from  side 
to  side;   condition  of  apathy,   resonance  of  patient^s  voice, 


190       DISEASES  OF  THE  AVtttCLE  AND  MEATUS. 

nausea  and  vomiting,  blepharospasm,  and  reflex  cough  are 
also  occasionally  met.  Patients  will  frequently  make  the 
statement  that  the  dulness  of  hearing  appeared  suddenly, 
which  may  be  explained  by  the  fact  that  the  plug  of  cerumen 
was  displaced  against  the  membrana  tympani  by  an  unusual 
movement  of  the  head  or  the  jaws,  or  the  impacted  debris 
became  swollen  through  the  imbibition  of  fluids  intentionally 
or  accidentally  introduced  into  the  canal. 

Diagnosis. — The  subjective  symptoms  will  often  appear 
vague  and  indefinite,  or  of  such  a  character  as  to  mislead  the 
physician ;  but  examination  with  the  speculum  will  reveal 
the  presence  of  a  ceruminal  mass,  which  may  appear  a  light 
yellow  or  dark  brown  in  color.  By  means  of  a  probe  its 
consistency  may  be  determined,  which  may  vary  from  a  soft 
greasy  mass  to  a  hard  inspissated  plug.  Frequently  it  will 
be  observed  that  the  centre  of  the  impacted  cerumen  is  solid, 
possibly  a  foreign  body,  around  which  a  softened  layer  has 
formed.  Exostoses  of  the  meatus  covered  with  cerumen,  in- 
spissated purulent  secretions  from  the  tympanum,  foreign 
bodies  of  cotton  or  paper  which  have  become  darkened  with 
age,  and  dried  clots  of  blood  may  be  mistaken  for  a  cerumi- 
nal mass. 

Prognosis. — In  uncomplicated  cases  careful  removal  of  the 
impacted  cerumen  will  be  attended  with  complete  restora- 
tion of  the  function  and  disappearance  of  the  symptoms  ;  but 
a  guarded  prognosis  should  always  be  made,  as  coincident 
afi^ections  of  the  membrana  tympani,  tympanum,  or  labyrinth 
may  be  present,  which  after  removal  of  the  debris  may  be 
attributed  to  the  manipulations  of  the  physician. 

Treatment. — The  most  effective  method  of  removing  the 
ceruminal  mass  is  by  means  of  a  forcible  syringing  of  the 
meatus  with  a  warm  alkaline  antiseptic  solution,  which  pro- 
cedure is  not  liable  to  injure  the  parts  nor  cause  much  dis- 
comfort, while  the  antiseptic  solution  will  lessen  the  danger 
of  infection  of  the  tympanum  should  a  previous  or  resulting 
perforation  of  the  drum  membrane  exist.  The  current 
should  be  directed  between  the  meatal  wall  and  the  impacted 
cerumen,    so    that    the    returning   stream    will    aid    in    the 


IMPACTED  CEHUMEN. 


191 


expulsion  of  the  mass.  When  the  ping  is  hard,  it  may  be 
necessary  to  continue  the  syringing  for  some  time,  as  it  re- 
quires an  imbibition  of  the  fluid  to  soften  the  matter  suffi- 
ciently for  its  removal.  The  questionable  procedure  of  advis- 
ing the  patient  to  make  repeated  instillations  of  an  oily  or 


Fig.  59. 


Bacon's  ear  syringe. 


alkaline  solution  into  the  canal  for  several  days,  with  the  in- 
tention of  softening  the  debris  before  attempting  its  removal 
by  means  of  the  syringe,  should  not  be  employed,  as  the 
resulting  swelling  of  the  inspissated  cerumen  may  damage  the 
surrounding  structures,  and  infection  may  be  carried  to  the 


Fig.  60. 


G.TIEMANN  a<.  CO. 

Pus  basin. 


tympanum,  through  a  perforation,  by  the  instilled  fluid.  To 
effect  properly  the  removal  of  the  mass  requires  the  use  of  a 
head-mirror  to  direct  the  light  into  the  canal,  a  large  syringe 
(Fig.  59),  a  pus  basin  (Fig.  60)  or  other  receptacle,  placed 
against  the  neck,  under  the  auricle,  to  catch  the  returning 


192        DISEASES  OF  THE  AURICLE  AND  MEATUS. 

flow,  and  a  towel  or  large  napkin  placed  upon  the  patient's 
shoulder  and  within  the  collar  to  protect  the  clothing.  The 
solution  to  be  used  in  the  syringing  should  not  be  contami- 
nated by  that  which  has  been  previously  employed,  especially 
if  a  perforation  be  suspected,  but  should  be  contained  in  a 
separate  basin.  Occasionally  it  may  facilitate  the  removal  of 
the  plug  of  cerumen  to  employ  a  pair  of  ear  forceps  (Fig.  61)  or 

Fig.  61. 


Ear  forceps. 


small  curettes  (Fig.  62) ;  but  great  care  should  be  exercised  that 
the  meatal  wall  or  the  membrana  tympani  be  not  injured  there- 
by.   After  the  canal  has  been  thoroughly  cleaned,  if  there  exists 


Fig.  62. 


— -s 


Ear  curette. 

any  irritation  of  the  skin  insufflations  of  boric  acid  may  be 
made,  and  the  meatus  closed  by  a  pledget  of  absorbent  cotton, 
which  should  remain  in  the  passage  for  a  day  or  so  to  pre- 
vent the  development  of  an  inflammation  within  the  canal  or 
tympanum  from  undue  exposure. 

FOREIGN   BODIES. 

Etiology. — From  time  immemorial  there  seems  to  have 
existed  an  inherent  tendency  in  children  to  insert  all  objects, 
whose  size  would  permit,  into  the  mouth,  nostril,  and  ex- 
ternal auditory  meatus.  In  a  playful  or  spiteful  mood 
they  frequently  perform  this  operation  upon  each  other,  and 
submit  to  the  procedure  with  mingled  joy  and  anticipation 


FOREIGN  BODIES.  193 

until  a  resulting  discomfort  terminates  the  act.  Buttons, 
beads,  pebbles,  seeds  of  various  kinds,  such  as  peas,  beans, 
wheat-kernels  and  coffee-beans,  pellets  of  paper,  cotton  and 
leaves,  pieces  of  matches,  tooth-picks,  and  pencils  are  some  of 
the  objects  that  find  their  way  into  the  youthful  meatus. 
Insects  of  various  varieties  frequently  enter  the  canal,  with  or 
without  the  knowledge  of  the  patient,  and  become  imprisoned 
by  the  ceruminal  secretions  or  the  numerous  hairs  of  the  car- 
tilaginous meatus.  If  the  membrana  tympani  be  reached,  a 
most  distressing  sensation  is  produced  by  the  frequent 
attempts  of  the  insect  to  effect  its  escape.  In  the  adult 
foreign  bodies  usually  obtain  their  presence  within  the  audi- 
tory passage  through  accident  or  malicious  intent. 

Symptoms. — As  in  the  case  of  impacted  cerumen,  foreign 
bodies  may  be  present  in  the  external  auditory  meatus  for 
years  without  producing  any  disturbance  in  function  or  sen- 
sation. Frequently  a  layer  of  cerumen  gathers  around  the 
object,  thus  increasing  its  occlusion  of  the  canal,  and  when 
this  is  sufficiently  accomplished  various  symptoms  make  their 
appearance.  If  the  foreign  matter  be  of  such  magnitude  and 
irregularity  as  to  obstruct  and  irritate  the  meatus,  the  patient 
will  complain  of  a  sensation  of  fulness  and  pain,  attended  with 
tinnitus  and  an  interference  of  hearing.  Should  the  foreign 
body  be  a  piece  of  wood,  a  bean,  or  any  other  substance  which 
would  swell  in  the  presence  of  moisture,  the  resulting  enlarge- 
ment would  be  productive  of  injury  of  the  surrounding  struct- 
ures and  occasion  a  great  amount  of  suffering.  Various 
reflex  phenomena  may  be  produced  through  irritation  of 
the  trifacial  and  vagus  nerves  which  distribute  filaments  to 
the  meatal  walls.  Persistent  cough,  nausea  and  vomiting, 
epileptic  attacks,  and  neuralgic  conditions  have  been  traced 
to  this  source,  and  relieved  by  removal  of  the  foreign  body 
from  the  canal.  With  a  sufficient  irritation  the  lining  mem- 
brane of  the  meatus  becomes  swollen,  ulcerated,  and  extremely 
painful.  Granulations  may  develop,  which,  together  with  the 
oedematous  condition  of  the  meatal  structures,  may  completely 
close  the  canal  and  hide  the  foreign  body  from  view,  although 
a  purulent  discharge  may  escape  from  the  lumen.     Secondary 

13— E.  E. 


194        DISEASES  OF  THE  AURICLE  AND  MEATUS. 

involvemeDts  of  the  tympanum,  labyrinth,  mastoid,  and  men- 
inges from  an  extension  of  the  inflammation  have  been  reported. 

Diagnosis. — By  means  of  the  specuhim  and  a  guarded  use 
of  a  probe  the  nature  of  the  obstructing  body  can  easily  be 
determined.  Its  consistence,  position,  size,  and  form  should 
be  noted,  as  these  features  will  demand  attention  in  effect- 
ing its  removal.  When  the  oifending  body  is  situated  deep 
within  the  canal,  and  especially  if  the  parts  be  swollen,  it 
will  often  be  difficult  to  ascertain  these  facts. 

Prognosis. — While  in  the  majority  of  instances  the  presence 
of  a  foreign  body  in  the  meatus  and  its  removal  are  not 
attended  with  any  special  annoyance  or  danger  to  the  func- 
tion of  hearing,  it  is  well  for  the  physician  to  be  reserved  in 
his  statements,  as  there  is  no  certainty  of  the  conditions  exist- 
ing beyond  the  obstruction,  especially  if  the  object  has  been 
in  the  canal  for  some  time  and  the  lumen  be  occluded. 

Treatment. — The  method  of  removing  a  foreign  body  from 

Fig.  63. 

3,    7L7frf='riT-"'"'""''''''''i'i'''"'"'J|^i-r'-"'"^?^ ■* 

I  ^g  ~  i^p,|..,j.niMiiiiiiiniiTiiip"""''     *— ' 

Hook  and  loop  for  removal  of  foreign  bodies. 

the  meatus  will  depend  upon  the  consistency,  location,  size, 
and  form  of  the  substance.  If  it  be  not  liable  to  enlarge 
by  the  absorption  of  fluids,  the  most  pleasant  and  effective 
procedure  will  be  a  syringing  of  the  passage  with  a  warm 
alkaline  antiseptic  solution  in  the  same  manner  as  previously 
indicated  in  the  removal  of  impacted  cerumen.  If  the 
parts  be  sufficiently  swollen  to  prevent  its  extraction,  the 
canal  should  be  kept  as  clean  as  possible  by  antiseptic 
irrigation  and  cold  applications  applied  to  the  auricle  or 
mastoid  with  a  view  to  reducing  the  inflammation  before 
making  further  attempts  at  displacing  the  offending  body. 
Should  the  syringe  fail  to  effect  its  expulsion,  various  instru- 
mental procedures  may  be  tried  by  means  of  forceps,  loops 
of  wire,  or  hooks  deftly  placed  around  and  behind  the  sub- 
stance with  the  intention  of  rolling  or  pulling  it  outward. 
Caution  should  be  exercised  that  the  foreign  body  be  not  acci- 


FOkElGN  BODIES.  195 

dentally  forced  inward  instead,  which  would  greatly  compli- 
cate the  condition. 

If  the  removal  be  not  accomplished  by  any  of  these 
methods,  operative  interference  oifers  the  only  means  of  ex- 
traction. No  definite  rule  can  be  given  to  guide  the  physi- 
cian in  determining  at  what  stage  recourse  should  be  made  to 
tlie  knife;  but  should  palliative  treatment  fail  to  check  or 
improve  the  conditions  present,  the  attendant  is  justified  in 
advising  an  operation.  This  procedure  consists  of  a  series  of 
incisions  whereby  the  posterior  part  of  the  auricle  and  carti- 
laginous wall  is  separated  from  its  attachments,  and  also  at 
its  junction  with  the  posterior  wall  of  the  osseous  portion,  so 
that  the  posterior  wall  of  the  cartilaginous  canal  may  be 
drawn  outward  and  forward,  when  instrumental  delivery  of 
the  foreign  body  will  be  facilitated.  If  the  body  be  impacted 
in  the  bony  portion  of  the  meatus,  it  may  be  necessary  to 
chisel  away  part  of  its  posterior  wall  to  reach  the  imbedded 
obstruction. 

When  an  insect  enters  the  canal,  it  is  best  to  terminate  its 
tormenting  struggles  for  liberation  by  instillations  of  an  oily 
preparation,  which  will  not  only  kill  the  intruder  and  form  a 
protective  to  the  irritated  lining  membrane,  but  also  facilitate 
its  removal  by  syringing.  The  larvae  of  blue-bottle  flies  are 
sometimes  found  in  the  meatus,  especially  in  cases  of  neglected, 
offensive,  purulent  discharges  from  the  tympanum  or  suppura- 
tive conditions  of  the  external  auditory  J[meatus.  If  they 
reach  the  tympanic  cavity  through  a  perforation,  it  is  difficult 
to  dislodge  them ;  but  the  procedure  outlined  above  will 
finally  effect  their  displacement,  especially  if  a  few  drops  of 
petroleum  or  turpentine  be  added  to  the  instillations,  which 
will  cause  them  to  migrate  from  their  abode  out  into  the 
canal,  from  which  they  can  be  easily  removed. 

QUESTIONS. 

What  are  the  common  affections  of  the  external  ear? 

Describe  the  malformations  of  the  auricle  and  the  external  auditory 
meatus. 

What  is  a  sebaceous  cyst  ?  its  treatment  ? 

What  is  the  differential  diagnosis  between  hsematoma  aura  and  perichon- 
dritis auriclae? 


196  LTSEASES  OF  THE  MIDDLE  EAR. 

Give  the  etiology,  symptoms,  and  treatment  of  diffuse  external  otitis. 

Give  the  etiology,  symptoms,  and  treatment  of  circumscribed  external 
otitis. 

What  are  the  usual  causes  of  impacted  cerumen,  and  how  is  it  best  removed  ? 

Name  the  various  forms  of  foreign  bodies  that  may  be  found  in  the  external 
auditory  meatus. 

Discuss  the  different  methods  of  their  removal. 

Why  should  the  physician  give  a  guarded  prognosis  in  cases  where  im- 
pacted cerumen  or  other  foreign  bodies  have  existed  in  the  canal  for  some 
time  ? 


CHAPTER   IV. 
DISEASES  OF  THE   MIDDLE  EAK. 

Classification. — Considerable  differences  of  opinion  as  to  the 
proper  anatomical  subdivision  of  the  middle  ear  and  the  classi- 
fication of  its  diseases  obtain  among  writers ;  but  inasmuch 
as  the  inner  surface  of  the  membrana  tympani,  tympanum, 
mastoid  process,  and  Eustachian  tube  is  invested  by  a  con- 
tinuous lining  mucous  membrane,  by  means  of  which  inflam- 
matory conditions  of  one  part  usually  extend  to  and  involve 
those  remaining  to  a  greater  or  less  degree,  and  as  the  condition 
of  all  exerts  some  influence  upon  the  transmission  of  sound,  it 
seems  productive  of  lucidity  to  consider  the  affections  of  all 
these  subdivisions  under  the  above  heading,  as  outlined  in 
the  opening  chapter.  Other  questionable  classifications  will 
be  indicated  in  the  succeeding  discussion. 

INJURIES    OF   THE   MEMBRANA   TYMPANI. 

The  drum  membrane  is  frequently  the  recipient  of  injuries, 
which  are  produced  by  either  a  traumatic  force  or  disturbance 
of  the  atmospheric  pressure  exerted  upon  the  outer  or  inner 
surface  of  the  membrane. 

Lesions. — Traumatic  lesions  usually  result  from  the  acci- 
dental or  intentional  introduction  of  foreign  bodies  or  sub- 
stances into  the  external  auditory  meatus,  when  abrasions, 
ulcerations,  perforation  or  rupture  of  the  membrane  may  be  pro- 
duced. A  bougie  introduced  into  the  tympanic  cavity  through 
the  Eustachian  tube  may  also  accidentally  injure  the  mem- 


INJURIES  OF  THE  MEMBRANA   TYMPANL  197 

brana  tympani.  The  use  of  matches,  tooth-picks,  hair-pins, 
ear-spoons,  and  various  other  objects  to  scratch  the  canal  or 
remove  the  cerumen,  as  employed  by  the  laity,  forms  a  pro- 
lific source  of  direct  injury  to  the  lining  of  the  canal  and  the 
membrana  tympani.  The  utmost  precaution  should  be  ob- 
served by  the  physician  in  the  use  of  instruments  within 
the  meatus,  as  very  distressing  forms  of  lesion  may  result 
from  an  accidental  manoeuvre  on  the  part  of  the  patient  or 
the  operator  while  performing  instrumental  manipulations  in 
the  region  of  the  drum  membrane.  The  position,  form,  and 
extent  of  injuries  in  this  structure  are  variable,  depending 
upon  the  direction  of  the  canal,  the  character  of  the  pene- 
trating object,  whether  it  be  pointed,  blunt  or  sharp,  rigid  or 
flexible,  smooth  or  roughened ;  and  the  force  with  which  it  is 
applied  against  the  membrane. 

Symptoms. — Coincident  with  instrumental  wounding  of  the 
membrana  tympani  a  loud,  rumbling  sound  is  heard,  accom- 
panied by  a  sharp,  piercing  pain.  Nausea,  vomiting,  dizzi- 
ness, tinnitus,  and  deafness,  or  an  unconsciousness  which 
terminates  the  agonizing  scene,  may  ensue.  After  a  time, 
depending  upon  the  extent  of  the  injury,  the  symptoms  will 
abate ;  but  with  the  development  of  a  reactive  inflammation  a 
throbbing  pain  and  harassing  noise  add  to  the  discomfort  of 
the  sufierer.  If  a  perforation  or  rupture  has  resulted,  with 
an  infection  of  the  tympanum,  a  painful,  suppurative  con- 
dition of  the  middle  ear  may  ensue  and  prolong  the  condition 
for  several  weeks,  with  a  possible  secondary  involvement  of 
the  mastoid  process.  If  the  abrasion  or  perforation  of  the 
membrane  be  small,  however,  in  the  absence  of  infection  resolu- 
tion will  occur  within  a  few  days,  with  little  or  no  alteration 
of  function ;  but  with  large,  irregular  ruptures,  permanent 
openings  through  the  drum  membrane  are  liable  to  remain, 
which,  together  with  the  formation  of  cicatrices  and  adhesions 
within  the  tympanum,  may  impair  the  hearing  markedly. 

Rupture  of  the  Membrana  Tympani. — Fractures  of  the 
cranial  bones  which  extend  into  the  external  auditory  meatus, 
sudden  condensation  of  the  air  upon  either  side  of  the  drum 
membrane,  and  the  hyperformation  of  fluids  within  the  tym.- 


198 


DISEASES  OF  THE  MIDDLE  EAR. 


panum  are  additional  factors  in  the  production  of  ruptures  of 
the  membrana  tympaui  (Fig.  64).  The  former  may  result 
from  blows  received  upon  the  mastoid,  temporal,  or  inferior 
maxillary  bones,  when,  if  the  fractures  involve  the  labyrinth 
or  cranial  cavity,  a  serous  fluid  may  escape  from  the  meatus, 
together  with  a  copious  hemorrhage,  which  indicates  a  most 
unfavorable  prognosis  for  the  restoration  of  function,  if  not 
for  the  patient's  life.  Suppuration  may  later  add  to  the  com- 
plexity of  the  condition.  Ruptures  resulting  from  a  sudden 
cliange  of  air  pressure  may  be  caused  by  a  slap  or  box  on  the 
auricle,  impaction  of  a  surf-wave,  the  proximate  discharge  of 
a  cannon  or  gun,  or  the  condensations  and  rarefactions  inci- 

FiG.  64. 


Rupture  in  the  anterior  inferior  half  of  the  membrane  of  a  boy  after  a  box 
on  the  ear.    (Politzer.) 

dent  to  the  inflation  of  the  Eustachian  tube,  and  the  use  of 
the  pneumatic  massage  otoscope  in  the  meatus.  In  the  latter 
instances  the  accident  is  usually  traceable  to  a  weakened  con- 
dition of  the  membrane,  due  to  the  presence  of  atrophic 
areas,  calcareous  deposits,  or  cicatrices.  It  is  w^ell,  therefore, 
always  to  examine  the  membrana  tympani  carefully  before 
employing  the  foregoing  procedures,  as  the  physician  may 
thereby  avoid  an  embarrassing  accident.  Perforation  or 
rupture  of  the  drum  membrane,  frequently  attendant  upon 
seropurulent  inflammatory  conditions  of  the  tympanum,  re- 
sults from  an  imprisonment  of  abnormal  secretion,  which 
finally  forces  its  way  through  the  path  of  least  resistance, 
the  inflamed   membrana  tympani,  to   the   external   auditory 


INJURIES  OF  THE  MEMBRANA    TYMPANI.  199 

meatus.  The  appearance  of  a  ruptured  membrane  result- 
ing from  noninflammatory  causes  will  vary  greatly,  depend- 
ing upon  the  method  of  production,  its  location  and  size, 
but  in  general  they  are  situated  in  the  antra-inferior  quad- 
rant, midway  between  the  centre  and  periphery  of  the  mem- 
brane, rarely  extending  the  whole  distance.  In  size  it  may 
present  an  elongated  slit  with  the  clean-cut  edges  slightly 
or  markedly  separated.  Adhering  near  the  edges  of  the 
wound  may  be  noticed  darkened  reddish  areas  of  coagu- 
lated blood.  Through  the  gaping  rupture  the  grayish-yellow 
mucous  membrane  of  the  normal  tympanum  may  be  seen, 
while  running  from  the  periphery  inward  a  few  congested 
bloodvessels  of  the  membrane  may  be  noted  in  the  affected 
quadrant.  Inflation  of  the  Eustachian  tube  produces  a  char- 
acteristic blowing  or  whistling  sound  as  the  air  escapes  through 
the  perforation  or  rupture  of  the  drum  membrane.  The  per- 
forations incident  to  inflammatory  conditions  of  the  tym- 
panum will  receive  further  consideration  under  that  subject. 

It  may  not  be  amiss  to  add  that  injuries  of  the  membrana 
tympani  frequently  present  a  medicolegal  aspect,  especially 
if  a  perforation  or  rupture  has  been  sustained,  when  the  phy- 
sician may  be  called  upon  to  testify  as  to  the  impairment  of 
audition.  In  general,  if  there  be  no  involvement  of  the  tym- 
panum from  infection  or  the  labyrinth  from  concussion,  and 
the  rupture  be  moderate  in  extent,  the  opening  will  close  in 
the  course  of  a  few  days  with  little  or  no  disturbance  of  func- 
tion. A  moderate-sized  permanent  opening  through  the 
drum  membrane  does  not  of  itself  materially  affect  the  ca- 
pacity for  hearing,  although  the  laity  usually  consider  it 
otherwise. 

As  regards  the  treatment  of  perforated  injuries,  it  is  best  to 
allow  Nature  to  take  her  course,  as  attempts  to  clean  the 
meatus  or  apply  antiseptic  measures  to  the  wounded  mem- 
brane may  be  the  means  of  carrying  infection  into  the  tym- 
panum. For  this  reason,  therefore,  syringing  of  the  canal 
or  instillation  of  drops  should  not  be  employed.  A  pledget 
of  absorbent  cotton  is  loosely  placed  in  the  canal  to  protect 
the  wound  from   external  influences  and  take  up  any  fluid 


200 


DISEASES  OF  THE  MIDDLE  EAR. 


that  may  be  formed.  If  an  inflammatory  condition  of  tlie 
tympanum  should  ensue,  its  treatment  would  be  that  of  an 
otitis  media. 


INFLAMMATION  OF  THE  MEMBRANA  TYMPANI. 

Pathological  alterations  of  the  drum  membrane  occur  either 
as  a  primary  affection  of  the  membrane  or  secondary  to  in- 
flammatory conditions  of  the  meatus  and  tympanic  cavity, 
tlie  latter  being  the  more  commonly  observed  form. 

Synonym. — Myringitis. 

Etiology. — The  condition  frequently  appears  as  an  idio- 
pathic affection.  It  may  be  noticed  coincident  with  a  naso- 
pharyngitis ;  following  an  unusual  exposure  to  a  cold  draft 
upon  the  ear ;  cold  baths,  douches,  and  sea-bathing  are  occa- 
sional causal  factors ;  instillations  of  various  irritating  and 

Fig.  65. 


Hypersemia  of  membrana  tympani. 

caustic  substances  into  the  meatus  are  usually  followed  by  a 
primary  inflammation  both  of  the  membrana  tympani  and 
the  lining  meatal  structures.  Traumatic  lesions  frequently 
extend  their  inflammatory  borders  well  into  the  surrounding 
membrane. 

Pathology. — The  first  evidences  of  a  myringitis  (Fig.  65) 
are  shown  by  a  slight  injection  of  minute  vessels  running 
from  the  periphery  toward  the  centre  of  the  membrane  and 
coalescing  with  those  which  course  along  the  region  of  the 
long  handle  of  the  malleus.     As  the  inflammation  develops, 


INFLAMMATION  OF  THE  MEMBRANA    TYMPANL     201 

the  hyperaemia  becomes  more  marked  until  a  diffuse  or 
striated  flush  envelops  the  whole  surface  of  the  drum  mem- 
brane and  involves  the  contiguous  dermal  layer  of  the  meatus. 
Coincident  with  the  development  of  the  hypersemic  condition 
a  serous  infiltration  of  the  epithelial  layer,  accompanied  by 
ecchymotic  areas  or  the  formation  of  clear,  transparent  vesi- 
cles, may  be  observed,  which  gives  the  membrane  a  dull, 
lustreless  appearance,  excepting  where  the  pearly  vesicles  are 
situated.  In  the  course  of  a  few  hours  the  vesicles  disappear 
by  absorption  or  rupture  with  a  discharge  of  the  serous 
contents,  which  may  later  become  sanguineous  in  character, 
leaving  a  ragged  excoriated  surface  behind.  Abscess  and 
ulcerations  of  the  membrane  sometimes  result  from  the  vesi- 
cles, though  this  is  a  rare  complication. 

Symptoms. — With  a  moderate  inflammatory  condition  the 
symptoms  are  not  specially  marked ;  a  varying  amount  of 
pain,  sensation  of  fulness  or  pressure,  some  tinnitus,  and  little 
or  no  disturbance  of  hearing.  In  marked  cases,  however, 
especially  if  attended  with  the  formation  of  vesicles  or  deep- 
seated  abscesses,  the  pain  becomes  intense,  particularly  at 
night,  and  may  continue  with  intermissions  for  several  days. 
An  ordinary  case  of  myringitis  usually  terminates  in  reso- 
lution within  the  course  of  a  few  days,  with  complete  cessa- 
tion of  all  symptoms. 

Diagnosis. — A  primary  myringitis  can  be  confounded  only 
with  the  secondary  form,  which  results  from  an  inflammatory 
condition  of  the  tympanum,  but  the  absence  of  marked  pain, 
with  little  or  no  disturbance  of  audition  would  indicate  a 
simple  inflammatory  condition  of  the  membrane.  In  an  in- 
volvement of  the  membrane  resulting  from  an  inflammatory 
condition  of  the  middle  ear,  however,  the  hearing  would  be 
considerably  impaired  by  the  presence  of  a  fluid  transudate, 
which  mechanically  interferes  with  the  transmission  of  sound. 

Prognosis. — As  previously  indicated,  the  termination  is 
usually  favorable,  resolution  occurring  within  a  few  days. 

Treatment. — As  the  symptoms  are  usually  not  marked  and 
the  course  of  the  disease  is  limited,  little  or  no  interference 
with  Nature's  course  is  necessary  •  but  it  might  be  well  to 


202  DISEASES  OF  THE  MIDDLE  EAR. 

syringe  the  canal  with  a  warm  alkaline  antiseptic  solution  to 
rid  it  of  infection,  and  after  drying  insert  loosely  a  pledget 
of  cotton  in  the  meatus.  If  the  membrane  becomes  ulcerated, 
insufflations  of  boric  acid  may  be  made  upon  the  surface. 
Abscesses  or  persistent  vesicles  may  be  emptied  by  paracente- 
sis, care  being  taken  that  the  instrument  does  not  pass  through 
the  whole  membrane,  as  an  infection  of  the  tympanum  might 
result. 


INFLAMMATION  OF  THE  EUSTACHIAN  TUBE. 

Synonyms. — Eustachian  tubal  catarrh  and  salpingitis. 

Etiology. — This  affection  of  the  Eustachian  tube  occurs  as 
an  acute  or  chronic  disorder.  The  most  frequent  cause  of  a 
congestion  or  inflammation  of  the  tubal  lining  membrane  is 
an  acute  coryza  or  acute  nasopharyngitis.  In  the  exanthemata 
of  childhood  tubal  obstruction  results  from  the  secondary 
involvement  of  the  nasopharynx.  Abnormalities  of  the  nasal 
or  pharyngeal  cavities  which  interfere  with  proper  respira- 
tion, such  as  adenoids  in  the  vault,  enlarged  turbinates,  septal 
deviations  and  spurs,  hypertrophied  follicular  tonsils,  irri- 
tating solutions  or  substances  which  may  reach  the  Eustachian 
orifice,  injuries  from  instrumentation,  and  impairment  of  the 
general  health  may  be  observed  as  causal  factors  in  the  pro- 
duction of  tubal  obstruction. 

Pathology. — As  the  mucous  membrane  of  the  Eustachian 
tube  is  continuous  with  that  of  the  tympanum  and  nasophar- 
ynx,  inflammatory  conditions  of  the  latter  frequently  extend 
not  only  to  the  tubal  lining  membrane,  but  occasionally  reach 
the  tympanic  cavity.  Within  the  tube  the  mucous  membrane 
may  present  simply  a  hyperaemic  or  injected  condition,  or  a 
true  inflammation  may  develop  therefrom.  In  the  latter  in- 
stance the  membrane  becomes  swollen  and  puffy,  the  lumen 
of  the  passage  is  markedly  decreased  or  obliterated,  transuda- 
tion of  a  fluid  adds  to  the  flabby  condition  of  ih^  mucous 
membrane,  and  finally  a  thick,  glairy,  tenacious  secretion 
completes  the  occlusion  of  the  tube.  As  the  cartilaginous  por- 
tion of  the  canal  is  the  more  vascular,  the  above-mentiond 


INFLAMMATION  OF  THE  EUSTACHIAN  TUBE.       203 

process  is  usually  confined  to  that  region.  With  the  closure  of 
the  Eustachian  tube  the  atmospheric  pressure  within  the  tym- 
panum is  reduced  through  the  rapid  absorption  of  the  con- 
tained air,  which  causes  the  membrana  tympani  and  ossicular 
chain  to  be  forced  inward  by  the  greater  atmospheric  pressure 
from  without.  If  the  tubal  obstruction  remains  sufficiently 
long,  the  drum  membrane  will  become  so  retracted  as  to  rest 
in  contact  with  the  promontory  of  the  inner  tympanic  wall. 
Later,  a  congestion  of  the  tympanic  vessels  may  occur  with 
the  formation  of  a  serous  transudation,  which  may  completely 
fill  the  cavity  and  exert  an  outward  pressure  upon  the  mem- 
brana tympani. 

Symptoms. — Coincident  or  following  the  development  of 
an  acute  inflammation  of  the  nasopharynx  the  patient  may 
experience  a  sensation  of  fulness,  numbness,  or  pressure  in 
the  meatus,  which  he  may  try  to  remove  by  inserting  the 
finger  into  the  canal  and  suddenly  withdrawing  it  in  such  a 
manner  as  to  create  a  vacuum.  Occasionally  sharp  or  dull 
intermittent  pains  may  be  noticed  within  the  tympanum  or 
pharynx.  Tinnitus,  high-pitched  in  character,  is  usually 
present.  Impairment  of  audition,  which  may  be  very  marked, 
mental  and  physical  torpidity,  a  feeling  of  numbness  about 
the  aural  region,  sensations  of  dizziness,  resonance  of  the 
patient's  own  voice,  and  a  snapping  sound  while  swallowing 
characterize  the  usual  line  of  symptoms.  Upon  inspection 
of  the  membrana  tympani  it  will  be  observed  that  the  mem- 
brane is  retracted  or  bulged  inward  to  a  greater  or  less  extent, 
depending  upon  the  duration  and  completeness  of  the  tubal 
obstruction.  The  lower  end  of  the  malleal  handle  is  drawn 
inward  and  backward  (foreshortened),  so  that  the  antra-in- 
ferior  surface  of  the  drum  membrane  appears  broader  than 
usual.  The  short  process  of  the  malleus  is  particularly  promi- 
nent, as  are  also  the  anterior  and  posterior  folds  of  the  ]nem- 
brana  flaccida  (Fig.  66).  The  cone  of  light  is  displaced,  dis- 
torted, or  absent.  With  inflation  of  the  tympanum  the  re- 
traction disappears  (Fig.  67),  and  the  function  of  audition  is 
instantly  restored,  the  sensation  of  fulness  and  numbness  dis- 
appears, and  the  patient  experiences  a  feeling  of  buoyancy ; 


204 


DISEASES  OF  THE  MIDDLE  EAR. 


but  after  a  time  the  symptoms  gradually  return  through  the 
absorption  of  the  air  within  the  tympanum. 

Diagnosis. — This  condition  is  diagnosed  by  the  presence  of 
the  foregoing  characteristic  symptoms  and  the  complete  resto- 
ration of  hearing  attendant  upon  inflation  of  the  tympanum. 
If  little  or  no  improvement  of  audition  follows  the'  inflation, 
however,  an  inflammatory  or  catarrhal  condition  of  the  tym- 
panum is  indicated.  Functional  examination  would  show  an 
elevation  of  the  lower  limit,  together  with  a  diminution  in  the 
duration  of  air  conduction.  If  only  one  side  were  affected, 
or  the  two  unequally  impaired,  Weber's  test  would  be  heard 
louder  in  the  one  more  seriously  involved. 


Fig.  66. 


Fig.  67. 


Appearance  of  membrana  tympani  in 
a  man  aged  thirty  years.    (Politzer.) 


Condition   of    membrana   tympani   in 
same  patient  immediately  after  inflation. 


Prognosis. — An  acute  salpingitis  dependent  on  an  acute  in- 
flammatory condition  of  the  nasopharynx  will  usually  disap- 
pear spontaneously  as  the  etiological  affection  improves ;  when 
the  tubal  obstruction  becomes  chronic,  however,  through  fre- 
quently repeated  attacks,  the  termination  often  is  questionable. 

Treatment. — Attention  should  be  directed  to  the  local  tubal 
trouble,  the  causal  conditions,  and  any  predisposing  systemic 
disorder,  to  effect  a  rapid  and  permanent  resolution.  To 
restore  the  hearing,  quiet  the  harassing  noises,  remove  the 
abnormal  sensations  about  the  ear,  relieve  the  patient  from 
his  mental  gloom,  and  quell  the  disturbances  of  equilibrium, 
repeated  inflations  of  the  tympanum  offer  a  panacea.  Either 
Politzerization  or  catheterization  may  be  employed  for  this 


INFLAMMATION  OF  THE  EUSTACHIAN  TUBE.      205 

purpose.  Occasionally  a  marked  stenosis  of  the  tube  is  encoun- 
tered, which  can  not  be  overcome  by  either  the  air-bag  or 
catheter,  and  is  liable  to  become  chronic.  In  this  condition 
recourse  may  be  made  to  the  bougie — whalebone  or  celluloid 
— (Fig.  68),  which  is  introduced  into  the  orifice  of  the  Eu- 

FiG.  68. 

Eustachian  bougie. 

stachian  tube  through  a  catheter,  and  very  gently  forced 
upward  through  the  canal  until  the  obstruction  is  encountered 
and  passed  if  possible.  Great  care  should  be  exercised  in  this 
procedure  lest  the  mucous  membrane  be  injured,  when  a  subse- 
quent inflation  might  result  in  an  emphysema  of  the  adjacent 
tissue.  In  the  chronic  form  of  tubal  stenosis  graduated  sizes  of 
the  instrument  are  employed  until  the  stricture  is  sufficiently 

Fig.  69. 


Bench's  vaporizer  with  catheter  attached. 


dilated  to  permit  normal  aeration  of  the  tympanum.  Stimu- 
lating vapors  of  alcohol,  ether,  chloroform,  or  tincture  of 
benzoin  may  be  applied  to  the  lumen  of  the  tube  by  means  of 
the  air-bag,  or  preferably  the  catheter,  with  vaporizer  attached 
(Fig.  69). 


206  DISEASES  OF  THE  MIDDLE  EAR 

As  to  the  treatment  of  the  nasopharynx,  this  is  always 
indicated  if  there  be  any  pathological  conditions  present, 
either  in  the  acute  or  chronic  form,  which  may  be  instru- 
mental in  the  production  or  prolongation  of  the  Eustachian 
involvement.  Free  nasal  respiration  should  be  obtained  by 
medicinal  or  surgical  procedures,  as  may  be  indicated.  In  the 
acute  forms  of  nasopharyngitis  much  can  be  accomplished  by 
the  judicious  use  of  a  warm  alkaline  antiseptic  spray,  fol- 
lowed by  local  applications  of  mild  solutions  of  cocaine,  or 
preferably  adrenalin,  to  the  swollen  inferior  turbinates,  after 
which  a  bland  antiseptic  oily  spray  may  be  applied  to  the 
nasal  cavity  as  a  protective.  The  writer  frequently  swabs 
the  pharyngeal  orifice  of  the  Eustachian  tube  with  an  adrenalin 
solution  (1  :  1000),  which  is  applied  by  means  of  an  appli- 
cator, followed  by  nitrate  of  silver  solutions  (4  or  6  per  cent.). 
In  the  chronic  forms  of  salpingitis,  the  nose  and  pharynx  are 
frequently  the  seat  of  pathological  conditions  which  interfere 
with  proper  nasal  respiration,  thereby  inducing  a  congestion 
of  the  tubal  structures  or  mechanically  obstructing  its  lumen. 
For  the  treatment  of  adenoids,  enlarged  turbinates,  septal 
deviations,  tonsillar  affections,  and  disorders  of  the  mucous 
membrane,  the  reader  is  referred  to  the  discussion  of  these 
subjects  elsewhere.  Any  predisposing  systemic  disorder  should 
receive  its  appropriate  treatment  as  indicated  in  works  upon 
general  therapeutics. 

INFLAMMATIONS   OF   THE   TYMPANUM. 

Introductory  to  the  consideration  of  this  subject,  it  may 
simplify  its  conception  to  note  that  inflammatory  diseases  of 
the  tympanic  cavity  occur  either  as  catarrhal  or  purulent  dis- 
orders. The  former,  which  appear  in  an  acute  or  chronic 
form,  are  characterized  by  a  thickened,  infiltrated  condition 
of  the  mucous  membrane,  with  a  serous  transudate  or  a  hyper- 
formation  of  its  normal  secretion,  resulting  from  either  a 
simple  hyperaemia  or  true  inflammatory  involvement  of  the 
lining  membrane ;  while  in  the  latter  conditions  the  reactive 
phenomena  extend  to  the  deeper  structures,  produce  a  more 


ACUT^  CATAHnBAL  OTITIS  MEDIA.  207 

or  less  violent  engorgement  and  swelling  of  the  mucous  layer, 
and  terminate  in  the  formation  of  a  mucopurulent  or  purulent 
secretion,  which  may  pursue  either  an  acute  or  chronic  course. 

ACUTE   CATARRHAL   OTITIS   MEDIA. 

Synonyms. — Acute  catarrhal  inflammation  of  the  middle 
ear ;  Otitis  media  catarrhalis  acuta  ;  Otitis  media  serosa. 

Etiology. — Sudden  changes  in  the  atmospheric  conditions, 
acute  coryza,  acute  pharyngitis,  influenza,  the  acute  exanthe- 
mata, stenosis  of  the  Eustachian  tube,  extension  of  infection 
to  the  tympanum  from  acute  or  chronic  catarrhal  conditions 
of  the  nasopharynx,  adenoids  in  the  vault,  stenosis  of  the 
nasal  cavity,  introduction  of  fluids  into  the  tympanum  while 
gargling,  bathing,  employing  the  nasal  douche,  or  violently 
blowing  the  nostrils,  and  general  debility  resulting  from 
various  systemic  disorders,  may  singly  or  combined  act  as 
factors  in  the  production  of  an  acute  involvement  of  the 
middle  ear. 

Pathology. — With  the  development  of  an  acute  tympanitis, 
the  superficial  structures  become  more  or  less  injected  or 
hypersemic,  accompanied  by  a  swollen,  infiltrated  condition 
of  the  lining  mucous  membrane.  A  serous  effusion,  mixed 
with  a  hypersecretion  of  the  mucous  glands,  soon  fills  the 
cavity  with  a  thin,  watery  fluid,  or  a  thick,  turbid  secretion 
which  macerates  the  mucous  membrane  and  holds  in  suspen- 
sion the  desquamated  epithelial  cells.  Owing  to  the  numerous 
folds  or  reduplications  of  the  mucous  lining,  the  process  is  fre- 
quently confined  to  the  attic,  while  the  remaining  part  of  the 
cavity  is  unaffected.  The  inner  layer  of  the  membrana  tym- 
pani  becomes  involved  in  the  inflammatory  condition  of  the 
tympanic  space,  which  weakens  its  resistance  through  the  proc- 
ess of  maceration  and  desquamation.  With  an  extension  of 
the  infiltration  to  the  fibrous  layer,  the  membrane  becomes  so 
devoid  of  strength  as  frequently  to  rupture  under  the  excess- 
ive pressure  of  the  tympanic  secretions.  The  inflammatory 
process  of  the  tympaniUTi  usually  affects  the  lining  membrane 
of  the  mastoid  process,  to  a  greater  or  less  extent,  through  the 


208  blSPAStlS  OF  THE  MIDDLE  EAR 

intervening  antrum.  The  Eustachian  tubal  structures  also 
are  generally  simultaneously  involved,  which  may  proceed 
from  the  tympanum,  but  usually  results  from  the  same 
causality  that  produces  the  tympanitis. 

Symptoms. — A  few  days  after  the  development  of  an  acute 
coryza  or  pharyngitis,  the  patient  may  notice  a  sensation  of 
fulness  in  the  Eustachian  tube  or  the  tympanum,  followed  by 
an  impairment  of  hearing,  tinnitus,  and  an  occasional  pain, 
which  may  be  dull  or  piercing  in  character.  As  the  disorder 
progresses,  the  symptoms  increase  in  intensity,  especially  the 
involvement  of  audition  and  the  sensation  of  pain.  If  the 
affection  occurs  in  a  child,  the  symptoms  would  seem  to  indi- 
cate the  presence  of  a  very  grave  condition,  as  they  are  more 
marked  than  those  usually  observed  in  the  adult.  Since 
the  trouble  frequently  develops  at  night,  the  little  sufferer 
appears  restless,  rolling  the  head  from  side  to  side  and  throw- 
ing the  arms  aimlessly  about.  Sometimes  the  hand  will  be 
applied  to  the  affected  region ;  but  usually  this  is  done  in 
such  a  manner  as  not  to  attract  the  attention  of  the  physician 
to  the  seat  of  the  pain.  A  concomitant  profuse  perspiration, 
increased  pulse-rate,  and  sudden  rise  of  temperature,  ranging 
from  102°  to  104°  F.,  give  a  clue  to  the  severity  of  the  affec- 
tion ;  but  the  attendant  is  frequently  none  the  wiser  until  a 
mucoserous  discharge  escapes  from  the  external  auditory 
meatus  several  hours  later,  to  the  astonishment  of  the  unsus- 
pecting observers.  This  is  usually  followed  immediately  by 
a  cessation  of  all  the  symptoms.  The  patient  becomes  quiet, 
drops  off  to  sleep,  while  the  temperature  gradually  returns  to 
or  near  the  normal  point.  In  the  adult,  however,  owing  to 
the  greater  resistance  of  the  membrana  tympani,  perforation 
of  the  membrane  does  not  occur  as  soon  or  often  as  with  the 
youthful  subject.  If  the  retained  secretions  be  not  liberated 
from  the  atrium,  they  are  liable  to  fill  the  attic  and  then 
extend  to  the  pneumatic  spaces  of  the  mastoid  process.  When 
this  occurs  the  patient  experiences  a  sensation  of  fulness,  pain, 
swelling,  and  tenderness  in  that  region.  Constitutional  dis- 
turbances, more  or  less  pronounced,  usually  make  their  appear- 
ance at  this  time.     The  patient  feels  exhausted,  both  mentally 


ACUTE  CATARRHAL  OTITIS  MEDIA.  209 

and  physically,  which  is  probably  due  in  great  measure  to 
loss  of  sleep  and  rest. 

The  character  of  the  discharge  varies  greatly,  not  only  in  dif- 
ferent individuals,  but  in  the  same  patient  from  time  to  time. 
It  may  be  a  clear,  serous  fluid,  or  a  thick,  turbid  secretion, 
which  may  stop  the  opening  in  the  drum  membrane  and  pro- 
duce a  return  of  all  the  symptoms.  An  intermittent  flow 
of  the  discharge  is  usually  traceable  to  this  cause,  although 
it  may  be  due  to  a  reparative  process  in  the  perforated  mem- 
brane. A  sudden  arrest  of  the  discharge  is  usually  indica- 
tive of  an  obstruction  to  its  escape  from  the  tympanum,  and 
should  always  be  regarded  as  an  unfavorable  symptom,  which 
demands  a  careful  investigation,  as  otherwise  great  damage 
may  result.  By  an  infection  from  the  meatus  the  catar- 
rhal form  of  otitis  media  may  be  changed  to  a  purulent 
inflammatory  condition,  which  is,  indeed,  an  unfortunate 
occurrence. 

Physical  Examination. — With  the  advent  of  the  affection 
the  membrana  tympani  may  first  show  a  condition  of  retrac- 
tion due  to  the  stenosis  of  the  Eustachian  tube.  The  vessels 
about  the  long  handle  become  injected  and  the  hyperaemic 
area  of  this  region  gradually  merges  into  the  normal 
periphery.  The  short  process  stands  out  prominently,  and 
the  lower  folds  of  the  membrana  flaccida  generally  present  a 
greater  degree  of  hypersemia  than  the  vibrating  portion, 
traceable  to  the  greater  vascularity  of  the  attic  with  its 
numerous  folds  of  the  mucous  membrane  and  thick,  spongy 
substructure  of  connective  tissue.  Later  the  whole  surface 
of  the  drum  membrane  becomes  reddened,  the  hyperaemia 
extending  even  to  the  lining  of  the  meatus,  being  especially 
marked  in  the  posterosuperior  wall  where  the  membrana 
tympani  seems  to  merge  into  the  meatal  epithelial  layer.  As 
the  fluid  forms  in  the  tympanic  cavity,  the  drum  membrane 
assumes  an  oedematous,  lustreless  condition  and  may  begin  to 
bulge  outward,  especially  in  the  posterior  portion,  from  the 
excessive  pressure  of  the  retained  morbid  secretions.  The 
epithelium  finally  becomes  so  macerated  that  it  is  desqua- 
mated as  a  whitened  debris.     This  process,  together  with  a 

14— E.  E. 


210  DISEASES  OF  THE  MIDDLE  EAR. 

similar  affection  of  the  inner  mucous  layer,  greatly  lessens  the 
resistance  of  the  tympanic  membrane,  and  thus  favors  the 
production  of  a  rupture  or  perforation. 

When  the  membrana  tympani  yields  to  the  disruptive  force 
of  the  tympanic  fluid,  a  mucoserous  discharge  escapes  from 
the  meatus  or  forms  a  yellowish  incrustation  within  the  canal 
through  evaporation  of  its  watery  constituents.  If  an  in- 
flation of  the  tympanum  were  now  performed,  the  air  would 
escape  from  the  perforation  with  a  hissing,  bubbling  sound, 
or  if  the  secretions  had  all  flowed  from  the  tympanic  cavity, 
the  note  would  be  sharp  and  whistling  in  character.  The 
site  of  the  perforation  may  be  located  by  a  small  hemor- 
rhagic area,  which  is  usually  differentiated  with  ease  from  the 
rest  of  the  altered  membrane. 

Functional  Tests. — As  a  rule  the  diagnosis  is  so  evident  and 
the  necessity  of  treatment  so  urgent  that  the  physician  does 
not  burden  the  patient  in  making  these  tests,  aside  from 
noting  the  degree  of  impairment  in  audition.  This  will  be 
found  to  be  more  or  less  reduced  ;  a  vibrating  tuning-fork 
placed  upon  the  vertex  of  the  skull  is  heard  more  distinctly 
on  the  affected  side;  air  conduction  appears  markedly  re- 
duced ;  the  lower  tone  limit  is  greatly  elevated,  while  the 
upper  is  normal  or  but  slightly  reduced. 

Diagnosis. — This  is  not  difficult  when  the  symptoms  of  ful- 
ness within  the  tympanum,  rapid  impairment  of  function, 
tinnitus,  and  aural  pain  are  supplemented  by  the  reddened  con- 
dition of  the  membrana  tympani,  the  existence  of  a  horizontal 
line  across  its  surface,  which  indicates  the  height  of  the  re- 
tained secretions,  a  bulging  in  the  posterior  or  superior  por- 
tion, or  the  evidence  of  a  perforation,  attended  by  a  muco- 
serous discharge  within  the  meatus.  The  only  condition  with 
which  this  may  be  confounded  is  an  acute  purulent  tympan- 
itis, which  can  be  differentiated  only  by  the  character  of  the 
discharge  as  it  escapes  into  the  meatus  from  a  spontaneous  or 
artificial  rupture  of  the  membrana  tympani. 

Prognosis. — The  termination  of  a  simple,  uncomplicated, 
acute  catarrhal  process  is  generally  favorable,  especially  with 
those  who  enjoy  a  healthful,  hygienic  mode  of  living,  and 


ACUTE  CATARRHAL  OTITIS  MEDIA. 


211 


when  an  early  disappearance  of  the  secretions  is  effected 
through  absorption,  spontaneous  perforation,  or  incision  of 
the  membrane.  When  removal  of  the  fluid  is  delayed, 
the  process  may  become  chronic  through  repeated  attacks, 
and    assume   either   a   hypertrophic   or   proliferative   condi- 


FiG.  70. 


Bacon's  scarificator. 


tion.  With  the  formation  of  cicatricial  bands  or  a  thick- 
ening of  the  mucous  membrane,  the  mobility  of  the  ossi- 
cles becomes  restricted,  with  a  resulting  impairment  of  hear- 
ing, which  is  more  commonly  observed  in  the  purulent  type 
of  involvement.     Obstinate  stenosis  of  the  Eustachian  tube. 


Fig.  71. 


Bacon's  cupping-glass. 


chronic  nasopharyngitis,  affection  of  the  labyrinth,  old  age, 
the  existence  of  systemic  disorders  attended  by  debility  and 
anaemia,  and  the  excessive  use  of  alcohol  are  regarded  as 
unfavorable  conditions. 

Treatment. — If  the  pain  be  particularly  marked  and  con- 


212  DtsmS£!S  OP  TBS  MWDLJS  MAtt. 

stitational  symptoms  be  evident,  the  patient  should  be  put  to 
bed,  a  saline  cathartic  given,  and  an  opiate  administered  to 
control  the  pain,  although  the  physician  should  be  careful 
that  the  drug  does  not  conceal  a  grave  condition,  as  the 
symptoms  may  be  entirely  masked  thereby.  The  abstraction 
of  blood  by  means  of  the  natural,  or  preferably  the  artificial, 
leech  and  cupping  (Figs.  70  and  71),  applied  in  front  of  the 
tragus,  is  often  abortive  in  the  early  stage.  Dry  heat  in  the 
form  of  a  hot-water  bag  may  also  be  used  with  benefit  in 
lessening  the  pain.  Should  the  nasal  cavity  be  obstructed  by 
a  swollen  condition  of  the  mucous  membrane,  the  stenosis 
may  be  relieved  by  first  cleansing  the  passages  with  a  warm 
alkaline  spray,  applying  a  cocaine  or  adrenalin  solution  to 
the  parts  by  means  of  an  applicator  or  spray,  followed  by  a 
bland,  oily  nebula  or  spray,  which  would  serve  as  a  protec- 
tive to  the  membrane.  In  case  a  pharyngitis  be  present,  a 
mildly  astringent  gargle  should  be  employed,  or  sprays  may 
be  used  instead. 

When  nasopharyngeal  inflammation  is  present,  the  Eusta- 
chian tube  usually  becomes  involved  from  an  extension  of 
the  process,  evidenced  by  a  retraction  of  the  membrana  tym- 
pani,  which  conditions  may  be  ameliorated  by  inflation  of 
the  tympanum,  together  with  the  treatment  of  the  nasophar- 
ynx indicated  above.  If  after  twelve  to  twenty-four  hours 
the  condition  has  not  shown  improvement,  the  canal  should 
be  syringed  with  a  warm  antiseptic  solution  (the  writer  pre- 
ferring carbolic  acid  (1:40)  on  account  of  its  anaesthetic 
properties),  and  an  incision  of  the  drum  membrane  made  in 
the  postra-inferior  quadrant  or  at  the  point  of  bulging, 
which  will  frequently  obtain  in  the  membrana  flaccida.  The 
canal  should  be  closed  with  a  bit  of  absorbent  cotton  or  a  strip 
of  gauze,  which  will  serve  as  a  protective  and  also  take  up  the 
discharge.  The  secretion  should  be  removed  at  least  once 
daily  by  syringing ;  by  use  of  the  applicator,  or  instillations 
of  warmed  hydrogen  peroxide  ;  the  meatus  dried  ;  boric  acid 
insufflations  made ;  and  the  cotton  or  gauze  replaced.  The 
cleansing  of  the  parts  should  not  be  intrusted  to  a  layman,  as 
infection  of  the  tympanic  cavity  is  liable  to  occur  thereby 


CHRONIC  CATARRHAL   OTITIS  MEDIA.  213 

and  add  greatly  to  the  seriousness  of  the  condition.  As  reso- 
lution takes  place,  inflation  of  the  tympanum  should  be  prac- 
tised to  prevent  retraction  of  the  drum  membrane  and  in- 
ternal adhesions.  So  marked  are  the  cessation  of  symptoms 
and  improvement  of  audition  following  an  incision  of  the 
membrana  tympani  that  the  writer  is  partial  to  this  method 
of  treatment.  In  the  course  of  a  week  or  so  the  discharge 
usually  ceases,  the  injection  of  the  membrana  tympani  dis- 
appears, and  the  function  of  hearing  gradually  returns  to 
normal,  providing  no  complications  be  present. 

CHRONIC    CATARRHAL    OTITIS   MEDIA. 

Synonyms. — Chronic  catarrh  of  the  middle  ear;  Chronic 
tympanitis ;  Otitis  media  catarrhalis  chronica. 

Etiology. — The  causes  of  a  chronic  catarrhal  involvement 
of  the  middle  ear  are  similar  to  those  which  are  productive 
of  the  acute  form  of  otitis  media,  but  a  chronicity  of  the  dis- 
order usually  obtains  only  with  prolongation  or  frequent 
repetition  of  the  etiological  conditions.  Chronic  catarrhal 
affections  of  the  nose  or  throat,  stenosis  of  one  or  both  nostrils 
by  the  presence  of  polypi,  septal  deviations,  or  hypertrophied 
turbinates,  adenoids  in  the  vault,  enlarged  faucial  tonsils 
which  may  mechanically  cause  a  stenosis  of  the  Eustachian 
canal,  the  frequent  taking  of  colds,  and  the  deleterious  effects 
of  a  changeable  climate  are  the  common  causes  of  this  affec- 
tion. A  delayed  resolution  of  an  acute  catarrhal  tympanitis 
predisposes  to  the  chronic  condition.  An  improper  action  of 
the  levator  or  tensor  palati  muscles  through  paralysis  or  other 
causes  may  lead  to  involvement  of  the  tympanum  by  improper 
ventilation.  General  disorders  which  impair  the  health,  ex- 
cessive use  of  alcoholic  drinks  or  tobacco,  and  hereditary 
predisposition  also  play  a  role  in  the  production  of  this  catar- 
rhal state. 

Pathology. — Chronic  catarrhal  otitis  media  occurs  in  two 
forms,  either  as  a  hypertrophic  (secretive)  or  hyperplastic 
(sclerotic,  adhesive)  catarrh  of  the  middle  ear.  In  chronic 
hypertrophic   otitis   media,    which   is   the   common  type   of 


214  DISEASES  OF  THE  MIDDLE  EAR. 

involvement,  the  pathological  alterations  consist  of  a  thick- 
ened vascular  condition  of  the  tympanic  mucous  membrane, 
which,  in  the  early  stage,  is  due  to  a  venous  congestion,  but 
later  to  a  true  hypertrophy  of  the  tissue  elements.  A  fluid 
exudate,  resulting  from  either  a  hypersecretion  of  the  per- 
verted mucous  glands,  a  transudation  from  the  bloodvessels 
of  the  engorged  lining  membrane,  or  a  mixture  of  both,  soon 
makes  its  appearance  as  a  characteristic  feature  of  this  condi- 
tion. The  secretion  may  nearly  fill  the  cavity  and  remain 
indefinitely  or  disappear  periodically  through  absorption  or  a 
lessened  activity  of  the  exciting  cause.  The  inner  surface  of 
the  membrana  tympani  also  assumes  the  pathological  changes 
of  the  tympanic  lining  membrane,  the  middle  or  fibrous  layer 
becomes  thickened,  and  occasionally  atrophic  areas  or  deposits 
of  calcareous  matter  occur  therein.  On  account  of  a  similar 
hypertrophic  process  in  the  mucous  lining  of  the  Eustachian 
tube  the  canal  becomes  chronically  stenosed,  the  tympanic 
congestion  increased,  and  the  drum  membrane  markedly 
retracted,  so  that  it  frequently  lies  in  contact  with  the  promon- 
tory, to  which  it  sometimes  becomes  adherent,  although  not 
so  often  as  in  the  sclerotic  form  to  be  described  shortly. 
With  prolongation  in  the  duration  of  retraction,  the  tendon 
of  the  tensor  tympani  frequently  becomes  shortened,  so  that 
inflation  of  the  tympanum  produces  little  or  no  change  in  the 
contour  of  the  membrane.  The  presence  of  the  tympanic 
secretion  and  thickened  condition  of  the  mucous  membrane 
about  the  articulations  of  the  ossicles  and  the  intratympanic 
ligaments,  together  with  the  retraction  of  the  drum  membrane, 
so  restrict  the  mobility  of  the  ossicles  that  the  function  of 
audition  is  more  or  less  impaired.  Involvement  of  the 
labyrinth,  which  might  occur  through  extension  of  the  proc- 
ess to  the  cochlea,  is  fortunately  a  rare  condition,  although 
it  sometimes  appears  in  cases  of  prolonged  severity. 

In  chronic  hyperplastic  otitis  media  the  hypertrophic 
mucous  membrane  of  the  preceding  condition  is  gradually 
replaced  by  an  atrophic  fibrous  tissue,  in  which  the  secreting 
glands  frequently  are  destroyed,  thus  constituting  the  so-called 
"dry  catarrh  of  the  middle  ear,"  or  otosclerosis.     Running 


CHRONIC  CATARRHAL   OTITIS  MEDIA. 


215 


through  the  exudative  debris  of  a  former  hypertrophic  state, 
connective-tissue  bands  are  formed,  which  ramify  in  various 
directions  across  the  tympanum  and  involve  the  ossicles 
(Fig.  72).     The  membrana  tympani  secondaria  in  the  fenestra 


an 


Section  through  the  tympanic  cavity  of  a  deaf  man :  h,  handle  of  the  malleus ; 
m,  tympanic  membrane;  ow,  annulus  tendinosus ;  st,  head  of  the  stapes;  /,  facial 
nerve;  6,  6',  b",  newly  formed  connective-tissue  bridges  in  the  tympanic  cavity: 
t,  t',  t",  spaces  in  the  tympanic  cavity  formed  by  these  membranous  bands.  (Politzer.) 


rotundum,  the  foot-plate  of  the  stapes  in  the  fenestra  ovalis,  and 
the  tissues  about  the  ossicular  articulations  become  involved  in 
the  adhesive,  sclerotic  process,  which  frequently  terminates  in 
complete  ankylosis  through  the  deposition  of  calcareous  matter, 


216  DISEASES  OF  THE  MIDDLE  EAR. 

with  serious  impairment  of  audition.  The  fibrous  bridges, 
adhesions  at  the  joints,  and  sclerotic  affection  of  the  mucous 
folds  and  ligaments,  especially  in  the  attic,  distort  the  position 
of  the  ossicles.  So  long  as  the  foot-plate  of  the  stapes  be  not 
immobilized,  and  the  labyrinth  be  unaffected,  the  hearing  may 
be  preserved,  but  unfortunately  these  structures  become  sooner 
or  later  implicated  in  the  general  sclerosis,  with  a  corre- 
sponding degree  of  deafness.  In  some  instances  the  mem- 
brana  tympani  becomes  thin,  with  marked  atrophic  areas,  and 
is  held  in  a  retracted  position  by  internal  adhesions,  especially 
to  the  promontory.  As  the  Eustachian  tubal  mucous  mem- 
brane shares  in  the  tympanic  alterations,  with  a  resulting 
undue  patency  of  its  lumen,  the  tympanum  is  thus  subjected 
to  a  liability  of  infection  and  traumatism  from  the  use  of  the 
nasal  douche,  the  act  of  sneezing,  and  the  blowing  of  the  nose. 
Symptoms. — In  both  the  hypertrophic  and  hyperplastic 
forms  of  chronic  otitis  media  the  first  indication  of  involve- 
ment is  usually  evidenced  by  an  impairment  of  audition, 
which  sometimes  comes  on  so  insidiously  that  the  unfortunate 
individual  is  often  unaware  of  his  affliction  until  a  marked 
alteration  has  occurred.  Frequently  in  the  hypertrophic  con- 
dition there  will  be  periods  of  exacerbation,  when  the  hearing 
will  be  seriously  lowered,  followed  by  an  improvement  as 
resolution  occurs,  but  after  a  time  the  function  does  not  return 
to  normal  because  of  the  pathological  alterations.  In  the 
hyperplastic  form,  however,  the  involvement  is  usually  pro- 
gressive, with  few  or  no  intermissions  of  improved  audition. 
A  harassing  noise — hissing,  blowing,  ringing,  or  whistling  in 
character — usually  accompanies  both  forms  of  this  disorder. 
In  some  instances  this  tinnitus  occurs  periodically,  while  in 
others  the  sounds  are  so  incessant  and  distressing  that  the 
patient  not  only  wearies  of  the  constant  din,  but  sometimes 
contemplates  rest  in  suicide.  These  subjective  sounds  fre- 
quently disappear  amid  external  noises,  but  return  with 
renewed  vigor  with  a  cessation  of  the  latter.  It  may  occa- 
sionally be  observed  that  the  patient  hears  better  when  in  a 
train,  mill,  or  surrounded  by  other  noises,  than  in  a  quiet 
place.     This  phenomenon  is  usually  attributed  to  an  increased 


CHRONIC  CATARRHAL   OTITIS  MEDIA.  217 

mobility  of  the  ossicles,  produced  by  the  greater  volume  of 
sound,  during  which  time  the  vibrations  of  lesser  intensity 
overcome  the  rigidity  of  the  ossicular  chain,  and  are  therefore 
more  easily  perceived.  Sometimes  this  condition  is  noted  in 
the  hypertrophic  form  of  involvement,  but  is  usually  charac- 
teristic of  the  sclerotic  or  hyperplastic  type  of  otitis  media. 
Pains  of  varying  duration  and  intensity  sooner  or  later  add  to 
the  discomfort  of  the  sufferer.  In  the  hypertrophic  condition 
the  patient  usually  complains  of  a  dull,  drawing  sensation  in 
the  tympanum,  or  a  burning,  neuralgic  feeling  in  the  region  of 
the  pharyngeal  orifice  of  the  Eustachian  tube,  especially  if 
stenosis  of  the  canal  occurs ;  while  in  the  sclerotic  disorder  the 
pain  is  periodical,  sharp  and  stinging  in  character,  of  short 
duration,  and  occurs  several  times  within  the  space  of  a  day. 

It  is  scarcely  necessary  to  add  that  one  side  is  usually  first 
affected,  although  both  may  be  involved  at  the  same  time. 
Impairment  of  hearing,  tinnitus,  and  pain  may  occur  simul- 
taneously, while  in  other  instances,  only  one  or  two  of  these 
symptoms  may  be  present.  An  almost  characteristic  symptom 
of  a  marked  hyperplastic  otitis  media  is  the  sudden  dulness 
of  audition  that  occurs  when  a  patient  attempts  to  listen  at- 
tentively. If  the  attention  be  not  directed  to  a  test  of  func- 
tion, the  hearing  will  be  fairly  good ;  but  when  an  effort  is 
made  to  perceive  a  conversation  or  particular  sound,  audition 
becomes  impaired  to  such  an  extent  that  the  patient  can  not 
hear  sounds  which  were  easily  recognized  a  moment  pre- 
viously. This  condition  is  probably  due  to  an  exhaustion  of 
the  auditory  centres.  So  marked  is  the  distress  produced  by 
the  harassing  noises  and  the  lowered  function  of  hearing  that 
a  general  debility  frequently  results,  with  a  perversion  of 
mentality. 

Physical  Examination. — If  the  Eustachian  tube  be  not 
markedly  involved,  the  membrana  tympani  in  both  the  hyper- 
trophic and  sclerotic  types  of  otitis  media  will  usually  present 
a  normal  appearance ;  but  more  frequently  a  retraction  of  the 
membrane  exists  as  a  result  of  stenosis  of  the  tubal  lumen  in 
the  hypertrophic  disorder,  while  in  the  hyperplastic  condition 
the  tube  is  generally  unduly  patent,     A  shortening  of  the 


218 


DISEASES  OF  THE  MIDDLE  EAR. 


Fig.  73. 


Atrophic  areas. 
Fig.  74. 


tensor  tympani  muscle  tends  to  hold  the  drum  membrane  in 
a  retracted  position,  especially  in  the 
latter  form  of  involvement.  Atrophic 
areas  (Fig.  73)  and  calcareous  deposits 
(Fig.  74),  together  with  adhesions  of 
the  membrana  tympani  to  the  promon- 
tory (Fig.  75),  are  frequently  observed, 
especially  in  old  cases.  The  use  of  the 
Seigel  otoscope  will  aid  in  the  differ- 
ential diagnosis  of  these  conditions.  In 
some  instances  the  membrana  tympani 
presents  a  thickened,  grayish  appearance, 
while  in  others  the  structure  is  so  uni- 
formly thin  and  transparent  that  the  in- 
cus-stapedial  articulation  may  be  seen, 
together  with  air-bubbles  or  fluids, 
within  the  tympanum. 

Functional  Tests. — The  acuity  for 
hearing  conversation  is  more  or  less 
impaired ;  tests  with  the  acoumeter  or 
watch  usually  show  less  involvement, 
although  this  order  may  be  reversed 
occasionally.  Patients  frequently  un- 
derstand one  person's  conversation 
more  distinctly  than  that  of  another. 
The  lower  tone  limit  is  elevated,  wdiile 
the  upper  limit  is  usually  normal  or 
slightly  altered.  Duration  of  air  con- 
duction is  shortened.  Bone  transmis- 
sion is  normal  or  increased  to  some  ex- 
tent, unless  the  labyrinth  be  affected, 
when  both  air  and  bone  conduction 
would  be  shortened,  and  the  upper 
tone  limit  correspondingly  lowered. 
With  the  Rinne  test,  if  the  tuning- 
fork  held  upon  the  vertex  be  heard 
more  distinctly  in  the  worse  ear,  the  middle  ear  alone  is 
affected ;    but,  if  perceived   more  readily  by  the  better  ear 


Deposits. 
Fig.  75. 


CHRONIC  CATARRHAL   OTITIS  MEDIA.  219 

an  involvement  of  the  labyrinth  on  the  opposite  side  is  indi- 
cated. 

Diagnosis. — In  uncomplicated  cases  of  chronic  catarrhal 
otitis  media  the  diagnosis  is  usually  not  attended  with  diffi- 
culty, as  is  also  true  in  the  differentiation  between  the  hyper- 
trophic and  hyperplastic  conditions.  A  chronic  impairment 
of  audition,  moderate  tinnitus,  dull  pains,  periods  of  improve- 
ment, stenosis  of  the  Eustacliian  tube,  a  thickened  condition 
of  the  membrana  tympani  with  retraction,  and  amelioration 
of  the  conditions  upon  inflation  of  the  tympanum  are  charac- 
teristic of  the  hypertrophic  state  ;  while  a  progressive  impair- 
ment of  hearing  with  no  intermissions  of  improvement,  a 
marked  tinnitus,  sharp,  stinging  pains  in  the  tympanum,  a 
thin,  adherent  condition  of  the  drum  membrane,  patency  of 
the  tubal  lumen  with  little  or  no  improvement  of  audition 
upon  inflation  are  indicative  of  a  hyperplastic  form  of  otitis 
media.  These  facts,  together  with  the  findings  of  the  func- 
tional tests,  clearly  point  to  the  location  and  character  of 
the  disorder. 

Prognosis. — As  a  structural  alteration  of  the  mucous  mem- 
brane is  the  chief  pathologicnl  condition  in  chronic  catarrhal 
otitis  media,  the  prognosis  should  always  be  guarded.  If  the 
labyrinth  be  unaffected,  the  function  of  audition  not  markedly 
lowered,  and  the  condition  has  resulted  from  intranasal  or 
pharyngeal  conditions,  which  are  amenable  to  medical  or 
surgical  procedures,  the  prognosis  may  be  regarded  as  favora- 
ble ;  but  with  intratympanic  adhesion,  atrophic  areas  in  the 
membrana  tympani,  a  thin,  flaccid  condition  of  the  drum  head, 
undue  patency  of  the  Eustachian  tube,  marked  retraction 
through  a  shortening  of  the  tensor  tympani,  a  progressive 
impairment  of  hearing,  sharp,  stinging  pains,  intense  tinnitus, 
and  a  weakened  physical  condition,  together  with  unhygienic 
surroundings,  the  prognosis  becomes  anything  but  favorable. 
Age  is  a  very  important  factor  to  be  considered  in  connection 
with  the  above  data,  as  the  younger  the  patient,  the  better 
are  the  chances  for  improvement. 

Treatment. — As  a  chronic  catarrhal  involvement  of  the 
middle  ear  usually  results  from  faulty  nasopharyngeal  condi- 


220  DISEASES  OF  THE  MIDDLE  EAR. 

tions,  it  is  imperative  that  any  pathological  alterations  in  this 
region  should  iirst  receive  the  physician's  attention.  Free 
nasal  respiration  should  be  enjoyed  at  all  times.  Stenosis  of 
the  nasal  passages  frequently  results  from  hypertrophy  of  the 
turbinal  bones  or  a  boggy  condition  of  the  overlying  mucous 
membrane,  together  with  the  presence  of  septal  deviations  or 
spurs,  and  polypi  or  adenoids  in  the  pharyngeal  vault,  which 
are  best  remedied  by  surgical  procedures.  Constitutional 
disorders,  which  may  exert  a  harmful  influence  upon  the 
aural  condition,  should  receive  appropriate  treatment.  In 
hypertrophic  otitis  media  the  Eustachian  tube  is  usually 
stenosed  by  a  thickened  condition  of  its  lining  mucous  mem- 
brane, which  frequently  disappears  under  proper  treatment  of 
the  nasopharynx  and  tubal  strictures,  with  a  gradual  im- 
provement in  the  retraction  of  the  membrana  tympani  and  a 
betterment  of  audition.  The  thickened  mucous  membrane 
about  the  pharyngeal  orifice  may  be  reduced  by  cleansing 
the  surface  with  a  spray  or  cotton  swab  attached  to  an 
applicator  which  is  curved  like  a  catheter,  and  then  making 
local  applications  of  nitrate  of  silver  (1  ;  24)  or  argyrol 
(1  : 3).  Should  the  stenosis  persist,  stimulating  vapor  of 
tincture  of  iodine,  ether  or  chloroform  in  small  quantities, 
ethyl  iodide,  or  campho-menthol  in  alcohol  (1  : 4),  may  be  in- 
troduced into  the  Eustachian  tube  and  tympanum  by  means 
of  either  the  air-bag  or  catheter,  the  latter  being  more  pref- 
erable. In  most  instances  a  judicious  employment  of  the 
bougie  will  hasten  resolution.  Astringent  solutions  are  some- 
times injected  into  the  tympanum  through  the  Eustachian 
tube,  or  an  artificial  opening  in  the  membrana  tympani,  for 
their  effect  upon  a  sluggish,  thickened  mucous  membrane ; 
but  this  procedure  should  be  left  to  the  specialist.  Aural 
massage,  which  has  for  its  object  the  securing  of  improved 
mobility  of  the  ossicles,  is  usually  not  indicated  in  the 
hypertrophic  state,  especially  when  active,  as  an  irritability 
of  the  condition  may  result  therefrom.  In  the  older  cases 
attended  with  marked  retraction  and  intratympanic  adhesions 
massage  may  be  tried ;  but  even  in  these  instances  care  should 
be  exercised  in  its  employment,  as  it  may  prove  detrimental 


OMkONiC  CATARRHAL  OTITIS  MEDIA.  221 

if  used  too  long  and  frequently.  Each  case  is  a  law  unto  itself 
in  this  respect ;  but  so  long  as  improvement  in  function  fol- 
lows its  use,  massage  is  indicated. 

In  the  hyperplastic  (sclerotic)  form  of  otitis  media,  as 
would  be  inferred  from  its  pathology,  the  physician  faces  a 
condition  over  which  he  has  little  or  no  permanent  control, 
yet  it  is  his  duty  to  stay  the  process  as  much  as  possible.  So 
long  as  the  foot-plate  of  the  stapes  be  not  immobilized  in  the 
fenestra  ovalis  by  adhesions  or  calcareous  deposits,  and  the 
labyrinth  be  not  affected,  temporary  improvement  may  be 
accomplished  by  aural  massage  and  guarded  forcible  inflations 
of  the  tympanum,  whereby  adhesions  may  be  lengthened  or 
possibly  separated  and  mobility  of  the  ossicles  improved. 
Often  no  betterment  of  audition  follows  this  procedure,  but 
a  diminution  of  the  harassing  tinnitus  may  be  accomplished, 
which  is  certainly  appreciated  by  the  sufferer.  Care  should 
be  taken  that  the  massage  be  not  applied  too' vigorously  or 
long,  as  the  noises  and  impaired  function  may  be  aggravated 
thereby.  Usually  the  process  may  be  continued  at  each  sit- 
ting until  a  flush  begins  to  appear  about  the  long  handle  of 
the  malleus,  when  the  treatment  should  be  discontinued. 
This  procedure  may  be  used  daily  if  carefully  performed. 
So  long  as  improvement  is  noticed  in  any  respect,  treat- 
ment should  be  continued  ;  but  if  otherwise,  it  should  be 
stopped.  Stimulating  inflations,  as  indicated  in  the  hyper- 
trophic state,  may  improve  the  vascularity  of  the  tympanic 
mucous  membrane,  but  are  usually  productive  of  no  results. 
Removal  of  the  ossicles,  mobilization  of  the  stapes,  and 
tenotomy  of  the  tensor  tympani  muscle,  each  has  its  advo- 
cates as  a  means  of  improving  audition  in  selected  cases  of 
chronic  catarrhal  otitis  media  ;  but  the  results  are  still  re- 
garded as  questionable.  In  the  line  of  medicinal  treatment 
sodium  iodide  (10  grains,  t.  i.  d.),  syr.  hydriod.  ac.  (1  drachm, 
t.  i.  d.),  and  pilocarpine  (J  grain,  t.  i.  d.,  and  gradually  in- 
creased) are  recommended  for  internal  use  as  a  means  of 
promoting  absorption  of  deposits  in  the  tympanum  and 
labyrinth. 


222  DISEASES  OF  THE  MIDDLE  EAR. 

ACUTE  PURULENT  OTITIS  MEDIA. 

Synonyms. — Otitis  media  acuta  suppurativa  ;  Acute  suppu- 
rative tympanitis ;  Acute  suppuration  of  the  middle  ear. 

Etiology. — Acute  purulent  inflammation  of  the  middle  ear 
is  induced  by  the  same  causes  that  operate  in  the  production 
of  the  acute  catarrhal  otitis  media.  As  a  result  of  climatic 
changes  this  disorder  occurs  more  frequently  during  the 
spring  and  autumn  months.  Acute  and  chronic  nasopharyn- 
geal catarrh,  colds,  scarlet  fever,  measles,  influenza,  typhoid 
fever,  smallpox,  and  various  systemic  disorders  are  frequent 
etiological  factors.  An  acute  catarrhal  otitis  media  may  be 
changed  to  the  purulent  condition  through  infection  intro- 
duced during  or  following  an  incision  of  the  membrana  tym- 
pani  for  therapeutical  purposes.  Operations  for  the  removal 
of  the  ossicles,  or  any  intratympanic  surgery  is  liable  to  be 
followed  by  a  purulent  infection.  Infection  of  the  tympanum 
sometimes  results  from  inflammatory  conditions  of  the  ex- 
ternal auditory  meatus.  Blows  upon  the  ear,  introduction  of 
cold  or  irritating  fluids  into  the  Eustachian  tube,  and  infla- 
tion of  the  tympanum  when  infective  material  is  lodged  in 
the  tubal  canal  may  be  mentioned  as  possible  routes  of  in- 
fection. 

Pathology. — In  the  early  stage  the  pathological  changes  are 
identically  those  of  an  acute  catarrhal  inflammation,  but  the 
process  is  more  intense.  The  transudation  from  the  engorged 
bloodvessels  is  rapid  and  extensive ;  white  blood-cells  escape 
into  the  swollen  tissue ;  necrosis  of  the  superficial  layers  of 
the  lining  mucous  membrane  takes  place,  and,  as  a  result  of 
the  marked  tumefaction,  the  blood-supply  of  the  ossicles  is 
seriously  restricted,  resulting  frequently  in  necrosis  of  the 
bones,  especially  the  incus,  if  the  process  be  long-continued. 
As  mentioned  previously,  the  attic  is  usually  the  site  of  this 
infective  process  on  account  of  the  numerous  folds  of  the 
mucous  membrane  and  its  thick,  spongy  structure  of  con- 
nective tissue.  Sometimes  the  swelling  of  the  folds  about  the 
ossicular  chain  is  so  intense  that  the  attic  is  shut  off*  from 
the  atrium  or  lower  part  of  the  tympanum.     In  this  case  the 


ACUTE  PUnULENT  OTITIS  MEDIA.  ^23 

purulent  secretion  is  very  liable  to  be  forced  into  the  mastoid 
cells  through  the  antrum,  or  secure  vent  through  the  mem- 
brana  flaccida.  As  the  tympanic  cavity  becomes  filled  with 
the  purulent  debris,  the  tension  upon  the  swollen,  macerated 
membrana  tympani  increases,  until  finally  its  weakened  struct- 
ure ruptures  and  the  secretion  escapes  into  the  external  audi- 
tory meatus. 

Symptoms. — The  symptoms  may  be  the  same  as  those  men- 
tioned under  acute  catarrhal  otitis  media,  but  usually  the  pain 
is  of  greater  severity  and  the  constitutional  disturbances  more 
marked.  The  symptoms  are  usually  of  greater  intensity  in 
the  child  than  with  the  adult,  and  are  more  severe  during 
the  night,  with  a  gradual  improvement  in  the  morning 
hours.  Any  physical  or  mental  exertion  aggravates  the 
pain.  The  general  w^eakness,  apathy,  and  emaciated  condi- 
tion indicate  the  severity  of  the  disorder.  If  the  mastoid  be- 
comes involved,  either  before  perforation  of  the  membrana 
tympani  occurs  or  subsequently,  the  local  and  constitutional 
disturbances  become  more  intense.  A  sharp  pain  is  referred 
to  the  mastoid  region,  tumefaction  of  the  overlying  tissues  is 
observed,  and  a  tenderness  is  elicited  upon  palpation  of  the 
part.  Occasionally  a  paralysis  of  the  facial  nerve  occurs  from 
an  extension  of  infection  to  its  structure.  Invasion  of  the 
meninges  is  indicated  by  an  increased  temperature,  convul- 
sions, delirium,  and  localized  paralysis,  if  the  brain  be  affected. 
Sliould  the  lateral  or  sigmoid  sinuses  become  involved,  symp- 
toms of  a  pysemic  infection  manifest  themselves  by  a  sudden 
rise  of  temperature,  reaching  105°  or  106°  F.  in  a  few  hours 
and  falling  with  equal  rapidity  to  normal  or  even  below  that 
point,  attended  by  profuse  sweating  and  chills,  which  may 
recur  at  intervals  of  a  few  hours  for  some  time. 

Following  a  spontaneous  or  artificial  rupture  of  the  mem- 
brana tympani,  a  seropurulent  or  purulent  discharge,  which 
may  be  tinged  with  blood,  escapes  into  the  external  auditory 
meatus.  So  rapid  and  complete  is  the  cessation  of  all  the 
symptoms  following  this  phenomenon  that  the  results  seem 
indeed  magical.  The  pain  disappears,  the  feeling  of  tension 
subsides,  the  temperature  gradually  returns  to  normal,  and  the 


224 


DISUSES  OP  THE  MIDDLE  EAR 


sufferer,  exhausted  both  mentally  and  physically,  drops  into  a 
refreshing  sleep.  In  the  course  of  a  week  or  two  the  dis- 
charge generally  subsides,  when,  if  the  perforation  be  not  too 
extensive,  the  wound  will  close,  leaving  naught  but  a  scar  to 
indicate  the  involvement.  Frequently,  on  account  of  a  caries 
or  necrosis  of  the  ossicles,  the  tympanic  wall,  or  the  mastoid 
cells,  the  discharge  continues  for  weeks,  and  may  finally  be- 
come chronic  in  character. 

Physical  Examination. — An  inspection  of  the  membrana 
tympani  in  the  early  stage  usually  reveals  an  injection  of  the 
membrana  flaccida,  which  gradually  changes  to  an  engorge- 
ment and  a  bulging  of  the  membrane  outward,  while  the 
larger  portion  of  the  drum  head  below  may  show  little  or  no 

Fig.  76. 


Bulging  of  membrana  flaccida. 

alteration  (Fig.  76).  As  the  process  advances,  the  whole 
membrana  tympani  assumes  a  dark-red,  lustreless  appearance. 
The  outlines  of  the  malleus  disappear,  the  short  process  be- 
comes indistinct,  and  the  surface  of  the  membrane  appears 
moist  from  the  extensive  oedematous  condition.  As  the  secre- 
tion fills  the  atrium,  a  secondary  bulging  of  the  drum  head 
may  appear  at  any  point,  but  is  usually  situated  in  the  postra- 
superior  quadrant,  on  account  of  the  fact  that  the  secretion 
trickles  down  the  incus  as  it  passes  from  the  attic  downward 
into  the  atrium.  It  is  at  this  point,  therefore,  that  a  sponta- 
neous perforation  usually  occurs ;  but  if  the  secretion  be  re- 
tained mainly  in  the  attic  on  account  of  an  intense  tumefaction 
of  the  mucous  folds  about  the  ossicles,  the  rupture  will  appear 
in  the  membrana  flaccida. 


ACUTE  PURULENT  OTITIS  MEDIA.  225 

Functional  Tests. — Again,  as  in  the  acute  catarrhal  otitis 
media,  the  condition  is  so  evident  and  the  treatment  so  urgent 
that  these  tests  are  not  usually  employed,  but  are  identically 
those  observed  in  the  catarrhal  affection  as  previously  indi- 
cated. As  the  labyrinth  is  more  liable  to  be  involved  in  the 
purulent  condition,  either  by  extension  through  the  fenestraova- 
lis  or  rotundum,  or  the  anastomosing  vessels  of  the  inner  wall, 
this  will  be  indicated  by  a  marked  lowering  of  the  upper  tone 
limit  and  a  diminution  in  the  duration  of  bone  conduction. 

Diagnosis. — As  the  signs  and  symptoms  of  an  acute  purulent 
inflammation  are  often  similar  to  those  of  an  acute  catarrhal 
process,  a  differential  diagnosis  can  not  be  established  with 
certainty  until  the  character  of  the  discharge  is  ascertained 
as  it  escapes  from  a  spontaneous  or  artificial  perforation.  The 
process  may  be  catarrhal  at  the  time  of  the  perforation,  and 
later  become  purulent,  as  evidenced  by  the  discharge.  In 
doubtful  instances  the  presence  of  a  perforation  may  be  diag- 
nosed by  (1)  ocular  inspection,  when,  if  the  opening  be  suffi- 
ciently large,  it  may  be  readily  seen  ;  (2)  the  escape  of  a 
secretion  through  the  drum  head,  if  the  perforation  be  not 
visible ;  (3)  hearing  the  characteristic  hissing  or  whistling 
sound  as  the  air  escapes  from  the  perforation  during  an  infla- 
tion of  the  tympanum  through  the  Eustachian  tube ;  and  (4) 
passage  of  the  air  into  the  nasopharynx  if  a  condensation 
of  the  air  in  the  external  auditory  meatus  be  practiced. 

Prognosis. — If  the  constitutional  condition  and  the  habits 
of  the  patient  be  good,  the  infection  be  of  primary  origin  or 
has  extended  from  an  acute  or  chronic  nasopharyngeal  inflam- 
mation ;  a  perforation  of  the  drum  head  has  occurred  within 
a  few  days,  which  gives  ample  drainage  to  the  tympanum  ;  a 
subsequent  rapid  improvement  in  all  the  symptoms  be  noted, 
and  there  be  an  absence  of  mastoid  involvement ;  the  prognosis 
may  be  regarded  generally  as  favorable  for  a  complete  restora- 
tion of  function.  On  the  other  hand,  infection  resulting  from 
scarlet  fever,  measles,  or  influenza  is  usually  very  severe,  and 
the  prognosis  is  frequently  unfavorable.  In  fact,  any  compli- 
cating systemic  disorder  usually  aggravates  the  local  condition. 

Treatment. — In  the  early  stage  vigorous  treatment   must 


226  DISEASES  OF  THE  MIDDLE  EAR. 

be  employed  if  the  condition  is  to  be  improved.  The  one 
measure  which  promises  the  greatest  satisfaction  is  the  ex- 
traction of  a  large  amount  of  blood  from  the  region  of  the 
tragus  by  means  of  the  natural  or  artificial  leech.  Dry  heat 
may  be  applied  to  the  external  ear  by  use  of  a  hot-water  bag. 
A  warm  antiseptic  solution  (carbolic  acid,  1  :  40)  may  be 
employed  in  syringing  the  external  auditory  meatus,  both  for 
its  soothing  effect  upon  the  condition  and  as  a  means  of 
cleansing  the  canal,  previous  to  a  perforation  of  the  mem- 
brana  tympani.  The  general  condition  of  the  patient  should 
also  receive  appropriate  attention.  If  the  symptoms  do  not 
improve  under  this  management,  and  especially  if  the  drum 
head  presents  a  bulging,  an  incision  of  the  membrane  should 
be  made  at  the  most  prominent  point,  which  is  usually  in  the 
membrana  flaccida  or  postra-inferior  quadrant  of  the  drum 
head.    In  operating  at  the  former  site  care  should  be  exercised 

Fig.  77. 


Knife  for  incision  of  drumhead. 


lest  the  incus  be  injured  or  displaced.  After  an  artificial  or 
spontaneous  perforation  has  been  made,  a  moderate  amount 
of  blood  escapes  with  the  purulent  secretion,  which,  if  abun- 
dant, is  regarded  as  favorable,  as  a  depletion  of  the  engorged 
structures  is  thus  assured.  The  canal  is  now  syringed  with  a 
warm  antiseptic  solution,  and  a  strip  of  sterile  gauze  placed 
loosely  in  the  passage  for  drainage  and  protection  from  ex- 
ternal influences.  As  the  packing  becomes  soaked  with  the 
secretion,  it  should  be  removed,  the  canal  cleansed  by  means 
of  the  syringe  or  a  cotton-tipped  applicator,  an  insufflation  of 
boric  acid  powder  made  upon  the  drum  head  for  its  antiseptic 
and  absorbent  properties,  and  a  strip  of  gauze  again  inserted  into 
the  canal.  If  the  discharge  be  abundant,  the  dressing  should 
be  replaced  several  times  daily ;  but  if  moderate,  once  or 
twice  a  day  will  usually  suffice.  It  is  best  that  the  treatment 
of  these  cases  be  not  referred  to  the  laity,  as  the  condition 


CHRONIC  PURULENT  OTITIS  MEDIA.  227 

may  be  aggravated  by  improper  procedures.  If  the  patient 
can  not  be  seen  as  often  as  desired,  after  the  usual  dressings 
have  been  made,  a  pad  composed  of  several  thicknesses  of 
sterile  gauze  may  be  placed  over  the  meatus,  where  it  may 
be  held  in  position  by  means  of  bandages,  which  serve  as  a 
protection  to  the  ear  and  take  up  the  discharge  as  it  escapes 
from  the  canal. 

Sometimes  the  original  perforation,  either  spontaneous  or 
artificial,  is  not  sufficiently  large  to  afford  proper  drainage, 
especially  if  the  discharge  be  copious  or  thickened  in  charac- 
ter. In  this  case  the  opening  should  be  enlarged  by  an  in- 
cision. Inflation  of  the  tympanum  and  rarefaction  of  the  air 
in  the  external  auditory  meatus  are  advocated  as  a  means  of 
removing  the  secretion  from  the  tympanum.  These  proced- 
ures are  not  only  usually  painful,  but  often  are  useless,  as  with 
proper  drainage  the  secretion  escapes  as  readily  as  it  is  formed. 

The  treatment  applicable  to  a  chronic  purulent  condition, 
and  in  cases  where  the  mastoid  becomes  involved,  will  be  con- 
sidered under  the  two  following  subjects. 

CHRONIC  PURULENT  OTITIS  MEDIA. 

Synonyms. — Otitis  media  chronica  suppurativa ;  Chronic 
suppurative  tympanitis ;  Acute  suppuration  of  the  middle  ear. 

Etiology. — This  disorder  results  from  either  a  preceding 
acute  catarrhal  otitis  media  which  has  become  infected  or  an 
acute  purulent  inflammation  in  which  for  various  reasons 
resolution  has  failed  to  occur.  An  acute  purulent  condition 
which  develops  during  an  attack  of  scarlet  fever,  measles, 
influenza,  tuberculosis,  syphilis,  or  scrofula  is  always  prone 
to  become  chronic  in  character.  Unhygienic  surroundings, 
insufficient  and  improper  foods,  and  the  abuse  of  alcohol 
aggravate  the  condition.  Local  conditions  in  the  tympanum, 
together  with  diseases  of  the  nasopharynx,  sometimes  also 
tend  to  the  production  of  chronicity.  Among  these  may  be 
mentioned  caries  or  necrosis  of  the  ossicles,  tympanic  wall,  or 
cells  of  the  mastoid  process ;  granulations  and  polypoid 
growths  springing  from  the  surface  of  the  tympanic  mucous 


228  DISEASES  OF  THE  MIDDLE  EAR. 

membrane  or  edges  of  the  perforation  in  the  drum  head ;  the 
retention  of  purulent  debris  within  the  tympanum  or  spaces 
of  the  mastoid  and  its  subsequent  caseation ;  purulent  and 
eczematous  conditions  of  the  external  auditory  meatus  by 
which  infection  is  carried  inward  to  the  tympanum  ;  and 
chronic  catarrhal  conditions  of  the  nasopharynx,  which  keep 
the  lining  mucous  membrane  of  the  Eustachian  tube  in  an 
irritable  state,  with  an  occasional  extension  to  the  tympanum. 

Pathology. — As  would  be  expected  as  a  result  of  the  chronic 
inflammation,  the  mucous  membrane  of  the  tympanum  is 
hypertrophied  and  vascular.  On  account  of  the  numerous 
folds  of  mucous  membrane  in  the  attic,  its  greater  vascularity 
and  thickness  of  its  connective  structure,  the  changes  are 
more  marked  in  this  region.  The  lining  membrane  becomes 
so  thickened  from  an  infiltration  of  round  cells,  the  formation 
of  new  bloodvessels,  and  the  dilatation  of  the  original  vessels 
that  the  tympanic  cavity  is  often  greatly  reduced  in  size. 
There  may  be  areas  in  which  the  mucous  membrane  is 
atrophic,  while  other  regions  show  not  only  the  hypertrophic, 
vascular  condition,  but  areas  of  granulation  as  well.  Areas 
of  bone  necrosis  may  be  present  in  different  portions  of  the 
tympanic  walls.  The  ossicles,  especially  the  incus,  may  be 
partially  or  completely  destroyed.  The  perforation  in  the 
membrana  tympani  is  usually  large  and  may  be  situated  in 
any  part  of  its  structure.  Sometimes  the  process  is  so  exten- 
sive that  the  entire  membrane,  together  with  the  ossicles,  has 
been  removed  by  the  discharge.  A  secondary  involvement 
of  the  mastoid  is  frequently  observed  and  constitutes  a  grave 
condition,  as  the  lateral  sinus  and  meninges  are  liable  to  be 
aflected  sooner  or  later  from  this  source,  although  an  erosion 
of  the  thin  upper  wall  of  the  attic  and  antrum  may  occur 
with  equally  fatal  results.  Extension  of  an  infective  process 
to  the  labyrinth  rarely  occurs,  although  the  foot-plate  of  the 
stapes  and  the  membrana  tympani  secondaria  may  be  bathed 
in  a  purulent  secretion  for  years. 

Symptoms. — The  only  symptom  of  which  the  patient  fre- 
quently complains  is  the  presence  of  a  discharge  in  the  meatus. 
This  may  be  so  abundant  that  it  escapes  from  the  canal,  or  so 


CHRONIC  PURULENT  OTITIS  MEDIA.  229 

scanty  that  only  a  scaly  incrustation  is  formed  in  the  meatus 
as  a  result  of  evaporation.  Often  the  discharge  will  stop 
for  a  time  and  then  appear  again,  following  an  attack  of 
rhinitis  or  pharyngitis  with  an  extension  of  the  inflammation 
to  the  tympanum,  or  infection  may  occur  from  without.  The 
hearing  may  be  seriously  affected  or  scarcely  impaired,  but 
this  is  not  dependent  upon  the  amount  of  discharge,  as  cases 
are  frequently  met  where  the  function  shows  but  little  alter- 
ation, while  the  secretion  is  copious.  Necrosis  is  usually  in- 
dicated by  a  characteristically  foul  odor  of  the  escaping  dis- 
charge and  the  presence  of  granulations  within  the  tympanum 
or  their  protrusion  through  a  perforated  drum  head.  As  a 
result  of  uncleanliness  granulations  frequently  appear  from 
the  edges  of  a  perforation,  and  may  be  so  extensive  as  to 
occlude  tlie  canal.  Polypoid  growths  also  frequently  spring 
from  the  membrana  tympani  and  vary  greatly  in  size,  usually 
approaching  that  of  a  small  pea,  although  the  waiter  has  seen 
them  not  only  fill  the  canal,  but  also  protrude  from  the  meatus 
like  a  miniature  cauliflower.  They  are  usually  of  a  mucous 
formation,  although  fibroid  polypi  are  sometimes  seen.  In- 
volvement of  the  labyrinth  to  a  slight  degree  is  commonly 
observed  in  cases  where  the  disease  has  existed  for  many 
years ;  but  fortunately  only  the  upper  tone  limit  is  altered, 
which  does  not  materially  affect  audition  for  conversation. 
The  symptoms  which  are  characteristic  of  a  sudden  involve- 
ment are  an  acute  dizziness,  nausea,  and  loss  of  hearing. 
Paralysis  of  the  facial  nerve  is  sometimes  observed ;  but  this 
usually  results  from  the  primary  acute  condition.  While 
constitutional  disorders  are  usually  one  of  the  causes  of  tlie 
chronic  purulent  tympanitis,  the  general  condition  of  the 
patient  frequently  suffers  from  the  local  disorder. 

Physical  Examination. — On  inspection  of  the  external  au- 
ditory meatus  a  great  variety  of  conditions  may  be  pre- 
sented. The  discharge  may  be  abundant  or  scant,  purulent 
or  mucopurulent,  fluid  or  inspissated.  The  lining  mem- 
brane of  the  canal  may  appear  normal,  eczematous,  or  irrita- 
ble and  excoriated  from  the  constant  presence  of  the  discharge. 
The  menabrana  tympani,  which  may  present  a  normal  or  r?d- 


230 


DISEASES  OF  THE  MIDDLE  EAR. 


dened  color,  will  reveal  one  or  more  perforations.  The  open- 
ing may  be  so  extensive  as  to  involve  the  greater  part  of  the 
membrane  (Fig.  78),  or  so  small  that  it  is  located  with  diffi- 
culty. The  perforation  may  occur  at  any  point  in  the  drum 
head,  but  is  more  often  observed  in  the  posterior  half.  Cal- 
careous deposits  are  also  frequently  seen  (Fig.  79),  which  may 
also  appear  at  any  point.  The  ossicles,  the  chorda  tympani 
nerve  as  it  courses  across  the  inner  surface  of  the  drum  head 
below  the  short  process,  the  promontory,  the  fenestra  ovalis 
and  rotundum,  and  granulations  may  often  be  seen  in  a  case 
of  large  perforation.  Granulation  and  polypoid  growths  have 
been  mentioned  previously.     Necrosis  of  the  internal  wall  or 


Fig.  78. 


Fig.  79. 


Large  perforation. 


Calcareous  deposits. 


ossicles  may  be  ascertained  by  a  judicious  employment  of  the 
probe,  when  a  roughened,  grating  sensation  will  be  imparted 
to  the  hand.  Inflation  of  the  tympanum  produces  a  hissing 
or  whistling  sound  as  the  air  escapes  from  the  perforation. 

Functional  Tests. — The  hearing  may  be  normal  or  mark- 
edly lowered ;  the  audition  for  conversation  may  be  greater 
than  that  for  the  acoumeter  or  watch,  or  these  conditions 
may  be  reversed ;  a  tuning-fork  placed  upon  the  forehead  or 
vertex  is  heard  better  in  the  aifected  or  worse  ear ;  the  lower 
tone  limit  is  raised,  while  the  upper  limit  is  normal  if  the 
labyrinth  be  unaifected ;  duration  of  air  conduction  is  short- 
ened, with  a  normality  of  bone  conduction,  although  it  may 
be  increased  ;  and  if  the  labyrinth  h^s  become  affected,  as  it 


CHROMIC  PURULENT  OTITIS  MEDIA.  231 

often  is  after  many  years,  the  npper  tone  limit  is  lowered  and 
the  bone  transmission  decreased. 

Diagnosis. — The  history  of  the  case  and  the  findings  of  the 
physical  and  functional  examinations  leave  no  uncertainty  as 
to  the  nature  of  the  condition.  Just  when  a  case  should  be 
regarded  as  chronic  has  not  been  arbitrarily  fixed ;  but  after 
a  discharge  has  continued  for  two  or  three  months  it  is 
usually  considered  chronic  in  character.  The  discharge  from 
a  chronic  eczematous  condition  of  the  canal  or  a  diffuse 
external  otitis  may  simulate  that  of  a  chronic  purulent 
otitis  media ;  but  an  inspection  will  reveal  the  absence  of 
a  perforation,  and  an  inflation  of  the  tympanum  will  not 
produce  an  escapement  of  air  from  the  external  auditory 
meatus. 

Prognosis. — In  making  a  complete  prognosis  it  is  neces- 
sary to  decide  as  to  the  restoration  of  hearing,  the  duration 
of  the  discharge,  and  the  risk  to  life  incurred  by  the  presence 
of  a  purulent,  inflammatory  condition  within  the  tympanum. 
To  answer  these  questions  properly  is  often,  indeed,  a  per- 
])lexing  matter,  but  in  general  it  may  be  stated  that  the  func- 
tional alterations  which  have  been  produced  after  several 
months  of  duration  will  probably  remain  unchanged  by  treat- 
ment, although  an  improvement  is  often  obtained.  Progres- 
sive deafness  is  not  so  characteristic  of  this  condition  as  is 
observed  in  the  chronic  catarrhal  otitis  media.  As  to  the 
duration  of  the  discharge,  this  will  depend  upon  the  presence 
or  absence  of  a  necrosis  of  the  ossicles  or  the  tympanic  wall, 
drainage  of  the  cavity,  and  involvement  of  the  mastoid  cells. 
With  the  securing  of  good  drainage,  removal  or  curettement 
of  necrosing  foci,  and  the  elimination  of  mastoid  complica- 
tions, the  prognosis  becomes  favorable.  Regarding  the  risk 
to  life  which  this  condition  presents,  it  may  be  stated  that 
life  insurance  companies  will  not  insure  an  individual  who 
has  a  chronic  purulent  otitis  media.  As  the  lining  mucous 
membrane  serves  as  a  periosteum  to  the  underlying  bone,  a 
purulent  affection  of  the  membrane  is  liable  to  attack  the 
bone,  and  thus  extend  to  the  intracranial  structures  by  way  of 
the  ^ttic  or  inuei"  wall  of  the  mastoid  process,  terminating  \n 


232  DISEASES  OF  THE  MIDDLE  EAR. 

a  meningitis,  phlebitis,  thrombosis,  brain  abscess,  or  pyaemia, 
from  which  recovery  is  doubtful. 

Treatment. — So  varied  are  the  conditions  that  may  be  pre- 
sented, that  only  a  general  outline  of  treatment  can  be  given. 
A  thorough  cleanliness  of  the  parts  and  the  securing  of  perfect 
drainage  are  first  to  be  considered.  The  discharge  may  be 
removed  from  the  meatus  by  means  of  syringing,  using  a 
warm  antiseptic  solution,  carbolic  acid  (1  :  40),  bichloride  of 
mercury  (1  :  5000),  or  boric  acid  (saturated  solution).  In- 
flation of  the  tympanum  or  rarefaction  of  the  air  in  the 
meatus  may  be  employed  to  remove  the  discharge  from  the 
tympanic  cavity.  Should  the  perforation  appear  too  small 
for  proper  drainage,  the  opening  should  be  enlarged  by  an 
incision.  If  the  discharge  be  abundant,  the  ^^  wet  treatment " 
should  be  employed  after  the  secretion  has  been  removed  by 
syringing  and  the  canal  and  drum  head  have  been  dried  by 
means  of  a  cotton-tipped  applicator.  This  consists  in  the 
instillation  of  antiseptic  or  astringent  solutions — e.  g.,  nitrate 
of  silver  (1  :  48),  argyrol  (1  : 4),  or  boric-alcohol  (1  :  24), 
after  which  a  strip  of  sterile  gauze  or  cotton  is  inserted  into 
the  meatus.  In  some  cases  it  may  be  necessary  to  change  the 
dressing  several  times  daily,  but  usually  once  or  twice  a  day 
will  suffice.  If  polypi  or  large  granulations  be  present, 
these  should  be  removed  by  means  of  forceps,  curette,  or 
snare.  Smaller  granulations  usually  disappear  after  the  use 
of  the  boric-alcohol  solution.  If  the  discharge  be  scanty, 
the  "  dry  treatment "  is  indicated.  The  secretion  is  removed 
by  means  of  a  cotton-tipped  applicator,  and  then  an  insuf- 
flation of  boric  acid,  alum  and  boric  acid  (equal  parts), 
aristol,  or  nosophen  is  made  into  the  tympanum  through  the 
perforation,  care  being  exercised  that  the  powder  be  not  suffi- 
cient to  interfere  with  a  proper  drainage.  A  piece  of  gauze 
or  cotton  inserted  into  the  canal  completes  the  dressing. 
Sometimes  it  may  be  necessary  to  alternate  the  wet  and  dry 
treatments.  After  employing  both  forms  of  treatment  for 
several  weeks,  if  there  be  little  or  no  improvement,  necrosis  is 
indicated,  especially  when  granulations  are  present  in  the 
tympanum  ^nd  ^  ch^racteristicallj^  foul  odor  remains  in  spite 


INFLAMMATION  OF  THE  MASTOID.  233 

of  thorough  cleanliness.  Instillations  of  iodoform-alcohol 
(saturated  solution)  are  recommended  in  this  condition ;  but 
if  these  prove  ineffectual,  the  advisability  of  removing  the 
ossicles,  especially  the  incus,  or  curettement  of  the  tympanum 
is  to  be  considered.  As  the  mastoid  cells  also  are  frequently 
involved,  it  may  be  necessary  to  clean  out  both  the  tympanum 
and  mastoid  before  a  cessation  of  the  discharge  is  obtained. 

Adhesion  of  the  perforated  membrana  tympani  to  the  prom- 
ontory is  frequently  seen  (Fig.  80),  which  fact  often  accounts 
for  a  marked  impairment  of  audition,  as  the  mobility  of  the 
membrane  and  ossicles  is  thus  restricted ;  but  so  long  as  the 
hearing  is  fairly  good,  it  is  best  not  to  attempt  their  separa- 


Adhesion  of  drumhead  to  promontory. 

tion,  as  the  condition  might  be  aggravated.  Moderate  and 
large-sized  perforations  usually  remain  patent  after  the  dis- 
charge has  ceased,  exposing  the  tympanum  to  reinfection  at 
any  time,  while  the  smaller  openings  frequently  close  spon- 
taneously, or  may  be  aided  in  this  process  by  irritation  of  the 
edges  by  means  of  nitrate  of  silver  solutions  or  a  curettement. 
Where  a  moderate  or  even  large  perforation  persists,  the  hearing 
often  can  be  improved  by  the  aid  of  an  artificial  drum  mem- 
brane, which  is  placed  in  contact  with  the  membrana  tympani, 
being  usually  composed  of  a  disk  of  rubber,  to  which  a  slender 
shaft  is  attached  as  a  means  of  introduction  and  removal.  A 
disk  of  paper  or  absorbent  cotton  may  be  used  instead. 


234  DISEASES  OF  THE  MIDDLE  EAR. 

INFLAMMATION   OF    THE   MASTOID. 

Synonyms. — Acute  or  chronic  mastoiditis. 

Etiology. — Involvement  of  the  mastoid  cells  occurs  as  a 
primary  or  secondary  disease.  The  former  condition  is  rare, 
resulting  from  traumatism,  exposure  to  cold  and  dampness,  or 
specific  diseases,  as  syphib's  or  tuberculosis.  The  latter, 
which  may  be  catarrhal  or  purulent,  results  from  an  exten- 
sion of  a  tympanic  inflammation  through  the  antrum,  as  a 
rule.  Infection  may  also  occur  through  the  postra-superior 
meatal  wall  from  inflammatory  conditions  within  the  external 
auditory  canal.  When  the  anatomy  of  the  tympanomastoid 
is  considered,  it  is  a  wonder  that  serious  involvement  of  the 
mastoid  cells  does  not  occur  more  frequently,  especially  when 
suppurative  inflammation  of  the  tympanum  is  of  long  dura- 
tion. Nevertheless  a  mastoiditis  is  liable  to  develop  at  any 
time  and  endanger  the  life  of  the  suiferer. 

Pathology. — With  every  inflammatory  condition  of  the  tym- 
panum there  is  more  or  less  congestion  of  the  lining  mucous 
membrane  of  the  mastoid  cells,  which,  together  with  the  fact 
that  a  secretion  in  the  tympanum  tends  to  flow  through  the 
antrum  into  the  mastoid  cells  when  the  patient  lies  upon  his 
back,  accounts  for  the  presence  of  pus  in  the  mastoid  of  every 
acute  purulent  otitis  media,  as  has  been  noted  by  Politzer.  So 
long  as  does  not  obtain  an  actual  inflammation  of  the  mastoid 
lining  membrane  no  symptoms  are  evident.  As  a  result  of 
the  chronic  congestion  of  the  mastoid  mucous  membrane, 
accompanying  a  chronic  purulent  otitis  media  hypertrophy 
of  the  tissues  lining  the  mastoid  cells  occurs,  with  an  infil- 
tration or  deposition  of  calcareous  matter,  which  often  oblit- 
erates the  pneumatic  spaces,  transforming  the  mastoid  process 
into  a  solid  bony  structure.  If  the  acute  congestion  or  chronic 
hypertrophy  of  the  membrane  lining  the  air-cells  be  sufficient 
to  close  the  openings  whereby  the  cells  communicate  with 
the  antrum  .and  infective  material  is  thereby  encased,  an 
abscess  may  develop,  with  necrosis  of  its  enclosing  walls. 
In  some  instances  the  communicating  openings  between  the 
mastoid  cells  and  antrum  are  large,  while  in  others  they  are 


INFLAMMATION  OF  THE  MASTOID.  235 

very  small,  so  that  a  congestion,  hypertrophy,  or  inflammatory 
cedematous  condition  of  the  lining  membrane,  which  in  one 
case  would  result  in  mastoid  involvement,  in  another  would 
prove  insufficient.  As  a  result  of  a  chronic  suppurative  mas- 
toiditis, necrosis  of  the  bony  walls  between  the  air-spaces  often 
occurs  to  such  an  extent  as  to  obliterate  them  entirely,  con- 
verting the  spaces  into  one  large  cavity,  which  may  be  filled 
with  granulation-tissue.  The  debris  of  necrosis  escapes  from 
the  tympanum  as  a  purulent  discharge  or  may  remain  within 
the  mastoid  as  a  caseated  mass. 

Symptoms. — If  the  disease  be  primary,  the  patient  will  com- 
plain of  a  feeling  of  fulness  or  tension  within  the  mastoid, 
accompanied  by  a  dull  constant  pain  behind  the  auricle,  which 
is  more  severe  during  the  night.  Within  the  course  of  a  day 
symptoms  of  a  tympanic  involvement  may  appear,  due  to 
extension  of  the  process  to  the  tympanum.  Constitutional 
disturbances  are  not  marked,  the  pulse  being  a  little  accel- 
erated and  the  temperature  raised  but  a  degree  or  so.  If  the 
tip  of  the  mastoid  be  involved,  movements  of  the  head  may 
increase  the  pain  in  the  mastoid,  due  to  the  traction  of  the 
sternocleidomastoid  muscle  upon  the  process.  CEdema  of 
the  overlying  tissues  frequently  occurs.  When  involvement 
of  the  mastoid  is  secondary,  the  symptoms  are  identically 
those  cited  above,  with  the  exception  of  a  previous  tympanic 
disorder  from  which  infection  of  the  mastoid  has  occurred. 
If  drainage  of  the  mastoid  abscess  through  the  tympanum 
has  not  been  obtained  or  be  inadequate,  the  discharge  will  be 
evacuated  from  the  mastoid  at  some  other  point  of  less  resist- 
ance. This  may  occur  through  the  external  cortex  or  from 
the  tip,  when  a  fluctuating  swelling  will  develop  at  the  point 
of  exit,  or  through  the  supra-posterior  wall  of  the  external 
auditory  meatus,  when  the  discharge  will  escape  into  the 
canal.  Involvement  of  the  intracranial  structures  may  occur 
through  the  intervening  bloodvessels  or  from  an  evacuation 
of  the  discharge  through  the  inner  wall  of  the  mastoid.  With 
the  development  of  meningitis  the  patient  complains  of  a 
headache,  which  may  at  first  be  intermittent,  but  later  be- 
corpes  constant  and  more  severe^  jitt^iided  with  photophobia, 


236  DISEASES  OF  THE  MIDDLE  EAR. 

restlessness,  insomnia,  nausea  and  vomiting,  and  a  constantly 
high  temperature.  A  characteristic  symptom  is  the  rigidity 
of  the  neck.  Paralysis  of  the  third  and  sixth  nerves  fre- 
quently intervenes,  with  a  resulting  dilatation  of  the  pupil 
and  strabismus.  With  a  localized  meningitis  or  extradural 
abscess  the  symptoms  are  less  severe  and  localized,  while  the 
rigidity  of  the  neck,  photophobia,  and  vomiting  are  absent. 
Involvement  of  the  lateral  sinus,  phlebitis,  is  indicated  by  a 
sudden  rise  of  temperature,  when  104°  or  105°  F.  is  fre- 
quently indicated,  followed  by  a  rapid  fall  to  the  normal 
or  subnormal  point,  attended  by  profuse  sweating  and  chills, 
which  may  recur  at  several  intervals  during  a  day.  As  the 
involvement  becomes  more  extensive,  symptoms  of  a  pysemic 
condition  become  more  pronounced.  With  the  development 
of  a  thrombus  disturbances  in  the  circulation  occur,  evidenced 
by  an  oedema  of  the  orbital  and  nasal  tissues.  As  the  throm- 
bus extends  downward  into  the  internal  jugular  vein  a  deep 
tenderness,  together  with  a  swelling  of  the  surrounding 
structures,  develops.  If  emboli  be  formed,  evidences  of  a 
metastatic  infection  occur,  which  in  the  lungs  usually  results 
in  a  septic  pneumonia.  With  the  development  of  a  brain 
abscess  the  symptoms  are  indefinite,  especially  in  the  early 
stages ;  but  when  observed  in  connection  with  the  existence  of 
an  acute  or  chronic  purulent  tympanitis  or  mastoiditis,  the 
presence  of  intracranial  pressure-symptoms,  a  pysemic  condi- 
tion, and  evidences  of  irritation  or  destruction  of  certain  areas 
in  the  brain  would  indicate  an  involvement  of  this  organ. 
With  a  chronic  abscess,  however,  the  symptoms  are  usually 
latent,  with  few  or  no  positive  indications  of  its  existence, 
until  a  hemorrhage  from  an  eroded  bloodvessel  or  rupture  of 
the  encapsulated  abscess  suddenly  renders  the  patient  coma- 
tosed,  accompanied  by  symptoms  of  paralysis.  The  acute 
form  of  brain  abscess  runs  its  course  within  a  few  days  or 
weeks,  depending  upon  its  location  and  development,  while 
a  chronic  abscess  may  exist  for  months  or  even  years  if  en- 
capsulated, as  it  usually  is. 

Physical  Examination. — If   the  mastoiditis  be  primary,  an 
inspection  of  the  membrana  tympani  may  later  show   evi- 


INFLAMMATION  OF  THE  MASTOID.  237 

dences  of  an  acute  catarrhal  or  purulent  tympanitis ;  while  if 
secondary  the  latter  conditions  would  be  present  before  the 
mastoid  involvement  occurred.  There  may  exist  a  swelling 
of  the  overlying  mastoid  tissues  or  areas  of  fluctuation  ;  but 
the  most  characteristic  signs  of  a  mastoiditis  are  a  tenderness 
of  the  region,  elicited  by  firm  palpation  as  compared  with  the 
opposite  side,  and  an  injection,  together  with  a  bulging  of  the 
postra-superior  wall  of  the  external  auditory  meatus  near  the 
annulus  tympanicus. 

Diagnosis. — When  taken  into  consideration  with  the  exist- 
ence of  an  acute  or  chronic  purulent  otitis  media,  the  develop- 
ment of  a  dull  or  sharp  pain  in  the  mastoid  region,  which 
increases  in  severity  at  night,  evidences  of  a  constitutional 
disturbance,  a  rigidity  of  the  neck  muscles,  oedema  of  the 
tissues  covering  the  mastoid  bone,  a  localized  tenderness  about 
the  antrum  or  tip,  and  a  bulging  of  the  postra-superior  wall 
at  its  inner  extremity,  considered  as  a  whole,  these  present 
a  characteristic  picture  of  a  mastoid  involvement.  A  differ- 
ential diagnosis  should  consider  inflammatory  conditions  of 
the  external  auditory  meatus  and  tympanum. 

Prognosis. — Inflammation  of  the  mastoid  process  should 
always  be  regarded  as  a  grave  condition  because  of  its  lia- 
bility of  extension  to  the  intracranial  structures ;  but  if  recog- 
nized early  and  appropriate  treatment  be  applied  the  prognosis 
is  usually  favorable  so  far  as  life  is  concerned.  Following  a 
chronic  purulent  otitis  media,  especially  when  the  perforation 
of  the  membrana  tympani  occurs  in  the  membrana  flaccida, 
which  indicates  a  marked  involvement  of  the  attic,  intercur^- 
rent  constitutional  disorders,  delayed  and  improper  treatment, 
and  the  weakened  resistance  of  old  age  are  unfavorable  con- 
ditions. 

Treatment. — If  seen  at  an  early  date,  the  condition  may  be 
aborted  by  anti-inflammatory  measures.  If  an  examination 
of  the  membrana  tympani  presents  evidences  of  a  bulging  or 
intratympanic  secretion,  an  extensive  incision  of  the  drum 
head  should  be  made.  If  an  original  spontaneous  or  artificial 
perforation  seems  inadequate,  it  should  be  enlarged  to  secure 
proper  drainage.   The  natural  or  artificial  leech  may  be  applied 


238  DISEASES  OP  TBE  MIDDLE  EAR 

with  benefit  over  the  region  of  marked  tenderness.  Cold  appli- 
cations are  of  great  value,  and  may  be  applied  by  means  of  an 
ice-bag,  or  preferably  with  the  Leiter  coil  (Fig.  81),  which 
may  be  molded  to  fit  the  mastoid  perfectly.  The  application 
should  be  constantly  employed  for  a  day  or  so,  when,  if  a 
marked  improvement,  especially  in  the  local  tenderness,  has  not 
occurred,  an  operation  is  indicated.  A  semicircular  incision 
(Wilde's)  through  the  overlying  mastoid  tissues,  made  one- 
half  inch  from  the  attachment  of  the  auricle,  is  highly  recom- 
mended by  some  writers  as  a  means  of  local  depletion  and  a 

Fig.  81. 


Leiter  coil. 


first  step  toward  a  radical  operation  if  necessary.  If  the 
inflammatory  condition  fails  to  improve  steadily  under  the 
abortive  treatment,  the  mastoid  should  be  opened  and  its  con- 
tents completely  removed  in  the  following  manner :  The  field 
of  operation,  instruments,  accessories,  and  hands  of  the  oper- 
ator having  been  prepared  for  an  aseptic  operation,  a  semi- 
circular incision  of  the  soft  parts  is  carried  from  a  point  about 
one-half  inch  above  the  attachment  of  the  auricle,  backward 
and  downward,  keeping  parallel  to  the  auricular  attachment 
and  terminating  at  the  tip  of  the  mastoid.  The  perios- 
teum is  now  elevated  or  dissected  from  the  bone  and  the 


INFLAMMATION  OF  THE  MASTOID. 


239 


osseous  structure  thoroughly  exposed  by  means  of  retractors, 
wliich  are  held  by  an  assistant,  tlie  auricle  being  pulled  for- 
ward so  as  to  lie  upon  the  side  of  the  head  (Fig.  82).  The 
hemorrhage  is  controlled  by  the  use  of  hot  sponges  and  artery 
forceps.  The  surface  of  the  mastoid  bone  is  thoroughly 
examined  for  areas  of  necrosis  or  the  existence  of  afistulous 


Fig.  82. 


Mastoid  process  opened  :  A,  antnim  ;  S,  tip  of  mastoid.    (Politzer.) 

opening,  especially  if  a  fluctuating  swelling  obtains  previous 
to  the  operation.  If  these  exist,  the  openings  are  enlarged 
by  means  of  a  gouge  or  a  chisel  and  mallet,  and  followed 
inward  to  their  origin.  Should  the  surface  present  a  healthy 
appearance,  the  primary  opening  of  the  mastoid  is  made  into 
the  antrum  by  means  of  the  chisel,  the  point  of  entrance  being 
effected  just  below  the  line  of  the  superior  wall  of  the  meatus 


240  DISEASES  OF  THE  MIDDLE  EAR. 

and  about  one-quarter  of  an  inch  backward  from  the  posterior 
wall  or  anterior  edge  of  the  mastoid  bone.  When  the  antrum 
has  been  exposed,  the  cortex  of  the  mastoid  is  chiselled  away 
from  this  point  downward  toward  the  tip  until  a  sufficient 
amount  has  been  removed  to  expose  thoroughly  all  parts  of 
the  mastoid  process.  The  cells  are  now  all  broken  down,  and 
every  vestige  of  a  necrotic  or  granulating  area  is  completely 
eradicated.  A  free  communication  of  the  antrum  with  the 
tympanum  should  be  established,  which  may  be  proved  by 
syringing  an  antiseptic  solution  into  the  antrum,  when  it  will 
escape  from  the  external  auditory  meatus  through  a  previous 
perforation  of  the  drum  head.  The  cavity  of  the  mastoid  is 
j)acked  with  sterile  gauze,  and  the  flaps  of  overlying  tissue 
allowed  to  regain  their  former  position,  when  a  gap  remains 
between  their  edges,  through  which  the  dressings  may  be 
changed.  A  thick  pad  of  gauze  is  placed  over  the  field  of 
operation,  and  retained  in  position  by  means  of  bandages  about 
the  head.  Tlie  dressings  are  changed  daily  or  less  frequently 
as  indicated,  until  the  cavity  becomes  perfectly  healthy,  when 
the  gaping  wound  may  be  closed  by  a  plastic  operation  if 
a  neat  cosmetic  result  be  desired. 

In  the  more  complicated  forms  of  mastoiditis  especially,  if 
the  process  be  chronic,  with  a  marked  involvement  of  the 
antrum  or  tympanum,  a  more  extensive  operation  will  be 
necessary  than  that  indicated  above.  In  some  instances  it 
will  be  advisable  after  opening  into  the  antrum  to  chisel  away 
the  intervening  supra-posterior  meatal  wall,  thus  throwing  the 
antrum  and  external  auditory  meatus  into  one  cavity ;  while 
if  the  tympanum  also  be  sufficiently  affected,  the  whole  inter- 
vening bony  structure,  together  with  the  membrana  tympani 
and  ossicles,  should  be  removed,  thus  converting  the  tym- 
panum, antrum,  and  external  auditory  canal  into  a  common 
cavity.  As  an  extensive  denuded  osseous  surface  results  from 
this  procedure,  some  form  of  plastic  operation  must  be  made 
to  dermatize  the  cavity.  This  is  accomplished  by  a  division 
of  the  postra-superior  meatal  lining  integument  (Fig.  83), 
whereby  one  or  more  flaps  are  formed.  After  the  auricle  is 
placed  in  its  normal  position,  the  flaps  of  skin  are  pressed 


INFLAMMATION  OF  THE  MASTOID. 


241 


against  the  posterior  and  superior  surfaces  of  the  cavity,  and 
retained  in  position  by  tampons  of  gauze,  which  are  changed 
as  occasion  demands.  The  flaps  of  integument  gradually 
grow  toward  each  other  until  the  whole  cavity  thus  becomes 
dermatized.  Whether  the  wound  behind  the  auricle  should 
be  partially  or  completely  closed  at  the  time  of  the  operation 
will  depend  upon  general  surgical  conditions,  but  it  is  better 

Fig.  83. 


I,  Longitudinal  incision  throxigh  the  posterior  wall  of  the  membranous  meatus ; 
S,  S',  superior  and  inferior  incisions  which  are  made  at  right  angles  to  c,  when  the 
concha  passes  into  the  auditory  meatus ;  1, 1/  superior  and  inferior  flaps  which  are 
made  from  the  posterior  wall  of  the  meatus.    (Politzer). 

to  err  upon  having  a  sufficiency  of  drainage  than  to  incur  the 
risk  of  retained  secretions. 

The  danger  of  a  mastoid  operation  lies  in  a  possibility 
of  injuring  the  lateral  sinus  or  facial  nerve,  and  the  acci- 
dental entrance  of  the  cranial  cavity,  whereby  infection  of 
the  brain  or  its  meninges  may  result,  though  fortunately 
this  is  a  rare  complication.  The  treatment  of  intercranial 
involvements  resulting  from  an  aural  affection  consists  in 
"-    16— E,  E. 


242  DISEASES  OP  THE  INTEBNAL  EAR. 

remedying  the  primary  condition,  together  with  such  spe- 
cific or  general  treatment  as  would  be  indicated  in  a  similar 
affection  uncomplicated  by  an  aural  disturbance. 

QUESTIONS. 

What  are  tlie  different  ways  whereby  the  membrana  tympani  may  be  in- 
jured? 

How  is  a  myringitis  differentiated  from  the  appearance  of  the  drum  head 
in  acute  otitis  media? 

What  are  the  signs  and  symptoms  of  a  stenosis  of  the  Eustachian  tube  ? 
Its  pathology  and  treatment? 

Give  the  etiology,  pathology,  signs  and  symptoms,  diagnosis,  prognosis,  and 
treatment  of  acute  catarrhal  tympanitis. 

What  are  the  pathology,  differential  diagnosis,  and  treatment  of  acute  puru- 
lent otitis  media  ? 

Give  the  etiology,  pathology,  differential  diagnosis,  prognosis,  and  treat- 
ment of  the  hypertrophic  and  hyperplastic  forms  of  chronic  catarrhal  otitis 
media. 

What  are  the  dangers  of  a  chronic  purulent  otitis  media  ? 

Give  the  pathology,  symptoms,  and  treatment  of  an  acute  inflammation  of 
the  mastoid. 

What  are  the  signs  and  symptoms  of  a  meningitis  resulting  from  an  aural 
infection  ? 

What  are  the  dangers  of  a  phlebitis  of  the  lateral  sinus?    Its  treatment? 


CHAPTER  Y. 
DISEASES   OF  THE  INTERNAL  EAR 

Notwithstanding  the  vast  amount  of  scientific  investi- 
gation which  has  been  expended  in  the  study  of  the  diseases 
of  the  labyrinth,  our  present  knowledge  of  the  pathology  and 
significance  of  certain  symptoms  is  still  very  incomplete. 
This  fact  is,  of  course,  due  to  the  inaccessibility  of  the  inter- 
nal ear  to  physical  examinations  during  life,  and  the  infre- 
quency  of  postmortem  opportunities  whereby  clinical  mani- 
festations of  aural  involvements  may  be  explained.  In  spite 
of  these  limitations,  however,  some  of  the  less  obscure  condi- 
tions are  fairly  well  understood. 

In  considering  the  disturbances  of  audition  referable  to  an 
affection  of  the  labyrinth,  it  should  be  remembered  that  patho- 
lotjical  alterations  which  interfere  with  the  function  of  the 


DISEASES  OF  THE  tNTEUNAL  EAtt.  243 

internal  ear  are  not  always  located  in  the  labyrinth  itself,  but 
may  be  traceable  to  the  presence  of  a  lesion  in  tlie  auditory 
nerve  or  its  cortical  centre  in  the  brain,  which  interferes  as 
effectually  with  the  power  of  hearing  as  though  the  disorder 
were  located  in  the  labyrinth  alone.  It  is,  therefore,  well  to 
regard  the  auditory  tract  as  part  of  the  perceptive  mechanism 
of  hearing.  Anaemic,  hypersemic,  hemorrhagic,  inflammatory, 
hypertrophic,  and  atrophic  alterations  are  the  conditions 
which  usually  account  for  an  involvement  of  the  labyrinthine 
function.  Although  a  primary  invasion  of  the  internal  ear 
sometimes  occurs,  the  disturbances  usually  appear  secondary 
to  a  local  or  systemic  disorder. 

On  account  of  the  intimate  vascular  communication  of  the 
tympanum  with  the  labyrinth  through  their  intervening  wall 
affections  of  the  former  sometimes  extend  to  the  labyrinthine 
structures.  When  associated  with  an  acute  catarrhal  or  puru- 
lent otitis  media,  the  pathological  alterations  may  consist  of  a 
hypersemia,  infiltration,  ecchymosis,  or  actual  inflammation, 
with  a  resulting  disturbance  of  the  intralabyrinthine  pressure. 
As  previously  indicated,  a  sclerotic  affection  of  the  vestibule 
and  cochlea  frequently  develops  in  the  course  of  a  chronic 
hyperplastic  otitis  media,  but  rarely  occurs  in  connection  with 
a  hypertrophic  process.  With  the  oncoming  of  old  age  a 
physiological  impairment  of  perception  occurs  as  a  result  of 
senile  changes  in  the  auditory  nerve  and  its  terminations  in 
the  cochlea.  Sclerotic  changes  in  the  membranous  labyrinth 
sometimes  appear  also,  which  terminate  in  an  ankylosis  of  the 
stapes. 

Owing  to  its  connection  with  the  intracranial  structures, 
inflammatory  conditions  of  the  brain  and  its  investments  fre- 
quently produce  a  temporary  or  permanent  impairment  of  the 
auditory  tract.  Most  productive  of  harm  is  an  epidemic 
cerebrospinal  meningitis,  which  is  so  frequently  observed  in 
childhood.  Hydrocephalus,  cerebral  tumors,  acute  or  chronic 
cerebral  abscesses,  acute  or  chronic  inflammations  of  the  brain, 
and  disorders  of  the  cerebellum  and  spinal  cord  may  also  be 
mentioned  as  etiological  factors  in  the  production  of  deaf- 
ness. 


244  DISEASES  OP  THE  INTERS  L  EAR. 

The  acute  exanthematous  diseases  are  very  productive  of 
impairment  in  the  perceptive  mechanism,  as  well  as  in  the 
tympanum,  especially  scarlet  fever,  measles,  influenza,  and 
diphtheria,  which  frequently  cause  a  hyperaemic,  ecchymotic, 
or  (Edematous  disorder  of  the  auditory  nerve  or  its  laby- 
rinthine terminations,  either  through  a  toxicity  of  the  blood 
or  secondary  inflammatory  conditions.  Because  of  the  sus- 
ceptibility of  the  auditory  tract,  and  the  frequency  of  acute 
infectious  diseases  during  childhood,  deafness,  resulting  from 
an  involvement  of  the  perceptive  tympanic,  as  well  as  the 
structures,  develops  more  often  during  this  period  of  life. 

The  following  influences  may  also  act  as  etiological  factors 
in  the  production  of  labyrinthine  changes :  specific  constitu- 
tional disorders  (tuberculosis,  syphilis,  and  uric  acid  diathesis), 
heredity  (often  overestimated),  certain  drugs  in  the  system 
(quinine,  salicylic  acid,  and  alcohol),  metallic  poisons  used  in 
the  arts  (lead,  mercury,  arsenic,  phosphorus,  and  carbon 
disulphide),  concussions  of  the  labyrinth  resulting  from  in- 
tense sounds  and  sudden  changes  in  atmospheric  pressure 
(report  of  cannon,  explosions,  escaping  steam,  and  the  effects 
of  a  blow  upon  the  auricle,  forcible  inflation  of  the  tympanum, 
and  sudden  rarefaction  of  the  air  in  the  meatus),  disturb- 
ances of  circulation  (thrombosis,  embolism),  and  affections  of 
the  mind  whereby  vasomotor  changes  occur. 

Symptoms. — In  general  it  may  be  stated  that  disorders  of 
the  perceptive  mechanism  manifest  themselves  by  symptoms 
of  irritation  or  paralysis.  In  the  former  conditions  the 
patient  complains  of  hypersesthesia  of  sounds,  tinnitus,  vertigo, 
nausea,  and  vomiting,  while  with  the  latter  dulness  of  hear- 
ing, qualitative  changes  in  perception,  or  deafness  are  noted. 
As  irritative  conditions  frequently  terminate  in  a  paralytic 
disorder,  a  combination  of  symptoms  occurs,  which  may  be 
elucidated  or  rendered  more  complex  by  the  presence  of  an 
incidental  or  causal  disorder  which  may  be  local  or  systemic 
in  character. 

Diagnosis. — Owing  to  the  vagueness  and  complexity  of  the 
symptoms  presented  in  an  involvement  of  the  internal  ear,  it 
is  necessary  to  resort  to  a  systematic  functional  test  as  a  relia- 


DISEASES  OF  THE  INTERNAL  EAR.  245 

ble  means  of  diagnosis ;  but  even  then  the  difficulties  are  not 
often  solved.  In  an  affection  of  the  auditory  tract  it  is  fre- 
quently impossible  to  decide  whether  the  lesion  be  located  in 
the  labyrinthine  terminations,  auditory  nerve,  or  its  cortical 
centre  in  the  brain.  A  simultaneous  disorder  of  the  tym- 
panum and  labyrinth  may  exist,  when  it  becomes  a  task 
to  determine  which  condition  accounts  for  impairment  of 
audition.  Quantitative  tests  (acoumeter,  watch,  or  voice) 
throw  no  light  upon  the  subject,  as  the  extent  of  impairment 
only  is  indicated  thereby.  By  means  of  the  qualitative  tests, 
however,  as  previously  noted  (page  32),  the  physician  can 
differentiate  between  affections  of  the  conducting  and  percep- 
tive mechanisms. 

Prognosis. — This  will  depend  upon  the  cause,  extent,  and 
duration  of  the  affection.  If  the  disorder  be  of  recent  date, 
the  impairment  of  hearing  not  marked,  and  the  causal  condi- 
tion can  be  remedied  or  improved,  the  prognosis  is  favorable 
for  restoration  of  function.  Chronic  impairment  with  a 
marked  loss  of  hearing  offers  an  unfavorable  termination, 
although  a  most  aggravated  condition  may  improve  to  a  satis- 
factory extent.  Involvements  of  the  perceptive  mechanism 
occurring  in  the  course  of  epidemic  cerebrospinal  meningitis, 
scarlet  fever,  and  measles  are  usually  regarded  as  serious,  so 
far  as  impairment  of  audition  is  concerned. 

Treatment. — Attention  should  first  be  directed  to  an  im- 
provement or  removal  of  the  etiological  condition.  In  the 
case  of  anaemia  of  the  labyrinth  due  to  a  systemic  disorder,  an 
abundance  of  nourishing  food,  systematic  out-of-door  exercises, 
and  the  use  of  iron  and  arsenic  preparations  internally  will 
usually  result  favorably.  Hypersemic  conditions  require  a 
depletion  of  the  system,  which  may  be  accomplished  by  the 
administration  of  salines.  Leeches  may  be  applied  locally, 
followed  by  cold  compresses.  The  diet  should  be  simple,  the 
habits  regular,  and  the  use  of  stimulants  avoided.  Hemor- 
rhagic and  inflammatory  affections  may  be  treated  in  a  similar 
manner.  Iodides  may  be  given  for  their  absorptive  effect. 
If  the  tinnitus  be  marked,  large  doses  of  sodium  bromide  may 
be  used  with  benefit. 


246  DISEASES  OF  THE  INTERNAL  EAR. 

QUESTIONS. 

Why  is  our  knowledge  of  the  pathology  of  disorders  of  the  perceptive 
mechanism  so  limited? 

What  are  the  common  affections  of  the  labyrinth  ? 

Give  the  etiology  of  diseases  of  the  internal  ear. 

How  do  disorders  of  the  perceptive  mechanism  manifest  themselves  symp- 
tomatica! ly  ? 

Why  will  a  lesion  in  the  auditory  centre  of  the  brain  produce  deafness  as 
effectually  as  though  it  were  located  in  the  labyrinth  ? 

How  are  affections  of  the  tympanum  and  labyrinth  differentiated  from 
each  other  ? 

What  is  the  prognosis  of  labyrinthine  disorders? 

Give  in  a  general  way  the  treatment  of  diseases  of  the  internal  ear. 


INDEX 


ABDUCTION,  135,  137 
Ablatio  retinae,  104 
Abrasion  of  cornea,  72 
Abscess  of  brain,  236 

of  cornea,  67 

of  external  auditory  meatus,  185 

of  lachrymal  sac,  35 

of  lid,  46 

of  mastoid,  234 

of  middle  ear,  222 
Accommodation,  27 

spasm  of,  133 
Adduction,  135,  137 
Adrenalin,  34 
Advancement,  140 
After-cataract,  97 
Albinism,  111 
Albuminuria,  101 
Alcohol,  114 
Alum,  33,  51 

Amaurotic  family  idiocy,  107 
Amblyopia,  108,  138 
Ametropia,  129 
Ampulla,  156 
Amyloid  degeneration,  63 
Anaemia,  101,  112 

of  labyrinth,  243 

of  optic  nerve,  112 

of  retina,  101 
Aneurism,  116 
Angioid  streaks,  107 
Angioma,  48,  64 
Aniridia,  84 
Anisometropia,  129 
Annulus  tympanicus,  145 
Anophthalmos,  117 
Anterior  chamber  of  eye,  20 
Antrum,  mastoid,  155 
diseases  of,  234 
operations  on,  238 
Aphakia,  97 
Aquseductus  cochlea,  157 

Fallopii-,  149 


Aquseductus  vestibuli,  157 
Aqueous  humor,  20 
Arcus  senilis,  75 
Argyll- Robertson  pupil,  86 
Argyria,  58 
Argyrol,  54 
Argyrosis,  58 
Aristol,  41 

Arterio-sclerosis,  120,  123 
Artificial  leech,  212 
Aspergillus,  65 
Asthenopia,  130 
Astigmatism,  129,  133 
Atrophy  of  conjunctiva,  61 

of  optic  nerve,  114 
Attic,  147 

inflammation  of,  207 
Auditory  meatus,  external,  144 
internal,  157 
diseases  of,  178 

nerve,  161 
diseases  of,  243 
Aural  massage,  220 
Auricle,  143 

diseases  of,  178 
Auscultation  tube,  168 

BACON'S  cupping-glass,  211 
scarificator,  211 

syringe,  191 
Basedow's  disease,  117 
Binocular  field  of  vision,  31 
Blake's  Eustachian  catheter,  170 

tuning-fork,  175 
Blenorrhcea  of  conjunctiva,  52,  54 

of  lachrymal  sac,  33 
Blepharitis,  37 
Blepharo-adenitis,  37 
Blepharoplasty,  48 
Blepharospasm,  46,  70 
Brain  abscess,  236 

disease,  44 
Buller's  shield,  55 

247 


248 


INDEX. 


Burn  of  conjunctiva,  80 
of  cornea,  72 
of  lid,  46 

CANAL,  external  auditory,  144 
Canaliculus,  32 

knife,  34 
Canthoplasty,  42 
Capsulotomy,  96 
Carcinoma  of  choroid,  110 

of  lid,  48 

of  orbit,  116 
Cardiac  disease,  46 
Cataract,  21,  88 

extraction  of,  95 
Cavernoma,  48 
Cellulitis,  116 
Central  retinal  artery,  25 
Cerumen,  impacted,  188 
Chalazion,  39 
Chancre,  43,  63 

Chemosis  of  conjunctiva,  19,  63,  116 
Choked  disk,  112 
Cholesterin,  100 
Chorda  tympani  nerve,  147 
Choroidal  pigment,  25 

ring,  25 
Choroiditis,  69,  109,  124,  132 
Cilia,  18 

Ciliary  region,  79 
Cochlea,  156 
Coloboma  of  choroid.  111 

of  iris,  47,  84 

of  lens  98 

of  optic  nerve,  115 
Color  field  of  vision,  30 

sense,  30 
Commotio  retinae,  107 
Concussion  of  eye,  83 
Congestion,  ciliary,  19 

of  eyeball,  19 

scleral,  19 
Conjunctiva,  19 
Conjunctival  discharge,  19 
Conjunctivitis,  49 
Corectopia,  84 
Cornea,  20 
Cornus,  115 
Corti,  organ  of,  160 
Crater-shaped  pupil,  80 
Cupped  disk,  123 
Cupping-glass,  211 
Cyclitis,  57,  69,  76,  86 
Cycloplegia,  129,  131 
Cyst  of  ciliary  body,  129,  131 


Cyst  of  conjunctiva,  64 
of  iris,  83 
of  orbit,  116 
sebaceous,  179 

DACKYO-ADENITIS,  32 
Dacryo-cystitis,  33 
Dacryops,  32 

Dalrymple's  symptom,  117 
Danger  zone,  87 
Bench's  tuning-fork,  176 

vaporizer,  205 
Dendritic  ulcer,  65 
Descemitis,  82 
Desmarres  forceps,  41 
Detachment  of  retina,  77, 104,  132 
Diabetes,  91,  101 
Diopter,  128 
Diplopia,  31,  136,  141 
Discission,  90,  97 
Diseases  of  external  ear,  178 

of  internal  ear,  242 

of  middle  ear,  196 
Dislocation  of  lens,  77,  124 
Distichiasis,  18 
Drumhead,  145 

diseases  of,  200 

incision  of,  200 
Duboisine,  81 

EAE,  anatomy  of,  145 
curette,  192 

external,  143 

forceps,  192 

internal,  155 

middle,  145 

syringe,  191 
Ecchymosis,  46,  63 
Ectasia,  70,  77 
Ectopia,  18,  43 
Eczema  of  lid,  37,  47 

external  auditory  meatus,  182 
Egyptian  ophthalmia,  55 
Electrolysis,  41 

Embolism  of  central  artery,  104 
Emmetropia,  130 
Emphysema,  46, 

inflation,  205 
Endarteritis,  104 
Endothelioma,  115 
Enophthalmos,  22,  117 
Entropion,  18,  41,  57 
Enucleation,  83,  100,  111,  119,  126 
Epicanthus,  47 
Episcleritis,  76 


INDJBX, 


m 


Epithelioma,  64 
Erysipelas,  47,  116 
Erythema,  47 
Esophoria,  136 
Eustachian  catheter,  170 

bougie,  205 

tube,  151 

diseases  of,  202 
Evisceration,  119 
Excision  of  lachrymal  sac,  35 
Exophoria,  136 
Exophthalmic  goitre,  117 
Exophthalmos,  22,  116,  117 
External  auditory  meatus,  144 

diseases  of,  178 
Eyeball,  22 

FACIAL  nerve,  149 
paralysis  of,  223 
Fenestra  ovalis,  148 

rotundum,  148 
Fibroma,  64,  115 
Field  of  vision,  27,  115 
Finsen  light,  48 
Follicularis,  52 
Forceps,  fixation,  94 

iris,  96 
Foreign  bodies  in  conjunctiva,  60 
in  cornea,  72 
in  eyeball,  118 

in  external  auditory  meatus,  192 
Fovea  centralis,  25 
hemispherica,  156 
Fundus,  24 

G ALTON'S  whistle,  177 
Ganglion  spirale,  161 
Glaucoma,  80,  87,  91,  97,  106,  115,  118 
Glioma  of  optic  nerve,  115 

of  retina,  106 
Gonococcus,  52,  54, 65 
Gonorrhoea,  78 
Gout,  51,  68,  76 
Graefe's  knife,  94 

operation  for  entropion,  42 
for  ptosis,  45 

symptom,  117 
Gumma  of  choroid,  110 

of  ciliary  body,  88 

of  conjunctiva,  63 

of  external  auditory  meatus,  188 

of  iris,  80,  84 ;  of  lids,  46 


H 


AAB  magnet,  118 
Hsematoma  auris,  180 


Hearing,  tests  of,  173 
Hemianopsia,  30 

Hemorrhage,  intra-ocular,  77,  97,  124, 
132 

from  ear,  198 

of  orbit,  117,  146 
Herpes  cornea,  74 
Heterophoria,  136 
Holmgren's  color  test,  30 
Hutchinson's  teeth,  69 
Hydrophthalmos,  118 
Hyperaemia  of  labyrinth,  243 

of  optic  nerve,  112 

of  retina,  101 
Hypermetropia,  136 
Hypopyon,  67,  82 

IMPACTED  cerumen,  188 
Incision  of  drumhead,  226 
Incus,  150 

Inflation  of  tympanum,  168 
Iridectomy,  81,  93,  112,  127 
Irideremia,  83,  84 
Iridocyclitis,  67,  77,  125 
Iridodialysis,  83 
Iridotomy,  127 
Iris,  20 
Iritis,  57,  67,  69,  76,  78,  91,  97 

plastic,  79 

purulent,  82 

serous,  82 

tuberculous,  82 

JACOBSON'S  nerve,  147 
Jsesche-Alt  operation,  42 
Jugulai-  fossa,  149 

KEEATITIS,  68 
Keratoconus,  71 
Keratoglobus,  118 
Keratome,  112 
Knapp's  roller  forceps,  58 
Konig's  rods,  176 
Kronlein  operation,  116 

LABYRINTH,  156 
diseases  of,  242 
Lachrymal  abscess,  35 
apparatus,  17,  31 
fistula,  36 
gland,  17,  31 
abscess  of,  32 
inflammation  of,  32 
prolapse  of,  32 
Lagophthalmos,  47 


250 


INDEX. 


Lamina  spiralis,  157 

membranous,  157 

osseous,  157 
Leiter  coil,  238 
Lens,  crystalline,  21 

dislocation  of,  21,  98 
Lenses,  127 
Lenticonus,  98 
Leucoma,  20,  53,  67 
Leukasmia,  101 
Levator  palati  muscle,  152 
Lid  retractors,  19 
Ligamentum  spirale,  160 
Light  sense,  30 
Limbus,  19 
Lipoma,  64 
Lithiasis,  51 
Lobule  of  ear,  144 
Locomotor  ataxia,  141 
Lupus,  46 

Luxation  of  lens,  98 
Lymphangiectasis,  63 

MACULA,  25 
acoustica,  159 

of  cornea,  20 
Madarosis,  37 
Magnet,  118 
Malaria,  QS,  76,  101 
Malleus,  150 

Massage,  middle  ear,  220 
Mastoid  abscess,  234 

antrum,  155 
diseases  of,  234 
Meatus,  external  auditory,  144 

.  diseases  of,  178 
Megalophthalmos,  22, 117 
Meibomian  gland,  cyst  of,  39 

scoop,  41 
Melanoma,  83 
Membrana  basilaris,  160 

tympani,  145 
Membrane  of  Corti,  161 

of  Eeissner,  160 

of  Shrapnell,  145 
Membranous  labyrinth,  158 
Meningitis,  113,  116,  236 
Metamorphopsia,  101 
Metastatic  conjunctivitis,  55 
Microphthalmos,  22,  117 
Miners'  nystagmus,  142 
Morgagnian  cataract,  93 
Mucocele,  33 
Muscles  of  auricle,  144 

external,  of  eye,  30,  135 


Muscles  of  levator  palati,  152 

stapedius,  153 

tensor  palati,  152 
tympani,  153 
Mydriatics,  85 
Myopia,  105,  129,  132 
Myosis,  85 
Myringitis,  200 
Myxoedema,  46 
Myxoma,  115 

\TASAL  catarrh,  51,  59 
il     duct,  17 

passages,  167 
Nasopharynx,  167 
Near  point,  27 
Nebula,  20 
Nephritis,  46,  112 
Night  blindness,  104 
Nose,  examination  of,  167 
Noyes,  forceps,  59 
Nyctalopia,  104 
Nystagmus,  142 

OBLIQUE  illumination,  20 
Occlusion  of  pupil,  80 
CEdema  of  drumhead,  209 
of  lid,  38,  46 
of  mastoid,  235 
of  optic  nerve,  113 
of  retina,  104,  107 
Onyx,  67 
Opacity  of  cornea,  66 

vitreous,  99,  133 
Ophthalmia  neonatorum,  52 

sympathetic,  78,  125 
Ophthalmometer,  130 
Ophthalmoplegia,  141 
Ophthalmoscope,  22,  129 
Ophthalmoscopic  examination,  24 
Optic  neuritis,  112 
Orbit,  21,  116 
Orthophoria,  136 
Osseous  lamina  spiralis,  157 
Ossicles  of  ear,  149 
Osteoma,  116 
Otitis  externa,  183 
circumscripta,  185 
diffusa,  183 
interna,  242 
media,  207 

catarrhal,  acute,  207 

chronic,  213 
purulent,  227 
a(!ute,  222 


INDEX. 


261 


otomycosis,  187 
Otosclerosis,  214 

PAGENSTECHEE'S  operation,  45 
Palpebral  fissure,  17 
Paiias  operation,  45 
Pannus,  57,  74 

Panophthalmitis,  57,  G7,  77,  100,  IIG 
Papilloma,  64 
I'aralysis  orbicularis,  43 

of  facial  nerve,  223 
Pemphigus,  63 
Perichondritis  auriculae,  181 
Perimeter,  30 
Periostitis,  116 

Pharynx,  examination  of,  1G7 
Phlegmon  of  lachrymal  sac,  35 
Phlyctenular  conjunctivitis,  59 

keratitis,  70 

ulcer,  65 
Photometer,  30,  137 
Phthiriasis,  47 

Phthisis  bulbi,  59,  67,  78,  118 
Pigmentation  of  cornea,  75 
Pinguecula,  63 
Pink  eye,  49 
Pinna,  144 
Politzer's  acoumeter,  174 

air  bag  169 

method  of  inflation,  169 
Polycoria,  84 
Presbyopia,  134 
Prisms,  128 

Processus  cochlear iformis.  149 
Prolapse  of  iris,  73,  83,  96 

of  lachrymal  gland,  17 
Promontory,  148 
Proptosis,  22,  116 
Protargol,  51,  54 
Pseudo-glioma,  100, 104 
Pteiygiura,  62 
Ptosis,  17,  43,  141 
Pulsating  exophthalmos,  117 
Punctum  lachrymale,  32 
Pupil,  21,  84 
Pupillary  membrane,  84 
Pyramid,  149 

RADIUM,  148 
Ke  fraction,  127 
Reissner,  membrane  of,  160 
Retina,  101 
Retinal  pigment,  25 

vessels,  25 
Retinitis,  101,  124 


Eetinoscope,  129 

Retraction  of  drumhead,  165 

Retrobulbar  neuritis,  113,  114 

Retroflexion  of  iris,  83 

Retrotarsal  fold,  19 

Rheumatism,  51,  68,  76,  112,  116 

Rickets,  68 

Rinne  test  175 

Rupture  of  choroid,  77,  111 

of  drumhead,  197 

of  eyeball,  77 

of  iris,  77 

SACCULE,  159 
Saeniisch  operation,  68 
Sarcoma  of  choroid,  110 

of  ciliary  body,  88 

of  conjunctiva,  64 

of  lid,  48 

of  optic  nerve,  115 

of  orbit,  116 
Scala  media,  160 

tympani,  157 

vestibuli,  157 
Sclera,  19 
Scleral  ring,  25 
Scleritis,  76 
Sclerochoroiditis,  110 
Sclerokeratitis,  76 
Sclerotomy,  124 
Scopolamine,  81 
Scotoma,  30,  114 
Scrofulous  conjunctivitis,  59 
Sebaceous  cyst,  125,  179 
Seborrhoea,  37 
Second  sight,  91 
Semicircular  canals,  156 
Septicaemia,  116 
Serpiginous  ulcer,  65 
Shadow  test,  129 
Shrapnell's  membrane,  146 
Sideroscope,  118 
Siegel's  otoscope,  166 
Sinus,  lateral,  155 

thrombosis  of,  236 
Snellen's  operation,  43 
Snow  blindness,  107 
Speculum,  Gruber's,  164 
Squint,  138 
Stapedius  muscle,  153 
Stapes  149 

Staphyloma,  53,  67.  76,  110,  132 
Stell wag's  sign,  117 
Stillicidium,  17 
Stye,  38 


252 

Subconjunctival  injections,  69, 

oycosis,  37  ' 

Symblepharou,  60 
Sympathectomy,  117,  124 
Sympathetic  irritation  127 

ophthalmia,  78,  125  ' 
Synchesis,  99 
Synechia,  80 

Syphilis,  44,  46,  63,  67   68   76 
101.  109,  112,  116,  141,  188  ' 

TARSAL  tumor,  39,  43 
Tarsorrhaphy,  43 
Tenotomy,  137,  139 
Tension,  26 

Tensor  palati  muscle,  152 
Test  case,  127 

type,  26 
Thompson's  lantern,  30 
Ihrombosis,  155 
Thyroidectomy,  117 
Tobacco  amblyopia,  114 
Tonsils,  diseased,  167 
Trachoma,  55 
Tremulous  iris,  21,  83 
Trichiasis,  18,  41,  57 
Tubal  diseases,  202 
Tube,  Eustachian,  151 

auscultation,  168 
Tumors  of  ciliary  body,  88 
of  conjunctiva,  64 
of  cornea,  75 
of  eyeball,  117,  124 
of  iris,  83 
of  lid,  47 
of  orbit,  116,  141 
vascular,  48 
Tuning-fork,  Blake's,  175 


INDEX. 


77 


78,  99, 


i  Tuning-fork,  Bench's,  176 
lurbinates,  enlarged,  167 
lylosis,  37 
Tympanic  cavity,  147 

diseases,  196 

plexus,  154 
Tympanum,  147 

ULCER  of  cornea,  57  64 
Umbo,  146  ' 

Utricle,  158 

yACCIJ^E  ulcer,  46 

^S^'^"  method  of   inflation, 

Van  Milligan  operation,  42 
Vestibule,  156 
Vision,  26 

field  of,  30 

testing,  26 
Vitreous,  21,  99 

WEBER'S  test,  177 
Wilde's  incision,  238 
Williams'  lantern,  30 
Wounds  of  ciliary  body,  88 
of  conjunctiva,  60 
of  cornea,  73 
of  drumhead,  196 
of  iris,  83 
of  sclera,  77 


XANTHALASMA;  48 
Xerosis,  57,  61 

y ELLOW  spot,  48 


&..        ./f-7-5^^- 


14  DAY  USE 

RETURN  TO  DESK  FROM  WHICH  BORROWED 

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LD  21-50w-4.'63 
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